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Ali S, Shebl FM, Aboian E, Strosberg D, Fischer U, Cardella J, Guzman RJ, Ochoa Chaar CI. The Utilization of Protamine during Peripheral Vascular Interventions in the VQI. Ann Vasc Surg 2024; 101:72-79. [PMID: 38110083 DOI: 10.1016/j.avsg.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/24/2023] [Accepted: 10/22/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Protamine administration was shown to reduce bleeding after carotid surgery but the role of protamine during peripheral vascular interventions (PVIs) remains unknown. This study evaluates the trend and outcomes of protamine use in the Vascular Quality Initiative (VQI). Our hypothesis is that the use of protamine is associated with decreased bleeding after PVI. METHODS Patients undergoing elective PVI in the VQI (2016-2020) for peripheral arterial disease were reviewed and the utilization trend for protamine was described. The characteristics of patients undergoing PVI with and without protamine use were compared. After propensity score matching based on the patient's comorbidities, access site, and procedural characteristics, the perioperative outcomes of both groups were compared using multivariable Poisson regression to estimate adjusted rate ratios (aRRs) and 95% confidence intervals (95% CIs). RESULTS The total number of patients was 131,618 and patients who received protamine constituted 29.8% of the sample (N = 38,191). After propensity matching, the total number of patients was 94,582, and patients who received protamine constituted 28.8% of the sample (N = 27,275). Protamine use significantly increased during the study period from 5.2 to 22.9%. Before propensity score matching, patients who received protamine were more likely to be white (79% vs. 76.8, P ≤ 0.001), smokers (80.5% vs. 78.5%, P ≤ 0.001), with medical comorbidities including hypertension (88.9% vs. 88.5%, P = 0.074), congestive heart failure (20.5% vs. 19.8%, P = 0.006), and chronic obstructive pulmonary disease (28.2% vs. 26.5%). They were also more likely to be on perioperative medications such as P2Y12 inhibitors (44.3% vs. 45, P = 0.013%) and statin (77.4% vs. 76.5%, P = 0.001) compared to patients who did not receive protamine. After propensity matching, there were no significant differences between the 2 groups. There was a significant decrease in bleeding during procedures where protamine was administered compared to no protamine (2.0% vs. 2.2%) (aRR, 0.89 [95% CI 0.80, 0.98]). Protamine was more likely to be given in procedures complicated by perforation (0.8% vs. 0.5%) (aRR, 1.48 [95% CI 1.24, 1.76]) and less likely to be given during procedures with distal embolization (0.4% vs. 0.7%) (aRR, 0.59 [95% CI 0.49, 0.73]). However, patients receiving protamine had significantly higher cardiac complications (1.4% vs. 1.1%) (aRR, 1.27 [95% CI 1.12, 1.43]). There was no significant difference in mortality between the 2 groups. CONCLUSIONS Protamine use is associated with decreased perioperative bleeding but increased cardiac complications. Protamine should be selectively administered to patients at high risk of bleeding during PVI.
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Affiliation(s)
- Sahar Ali
- Vascular Surgery Department, Assiut University Hospital, Faculty of Medicine, Assiut, Egypt.
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Edouard Aboian
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - David Strosberg
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Uwe Fischer
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Jonathan Cardella
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Raul J Guzman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
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Hyle EP, Wattananimitgul N, Mukerji SS, Foote JHA, Reddy KP, Thielking A, Yu L, Viswanathan A, Rubin LH, Shebl FM, Althoff KN, Freedberg KA. Age-associated dementia among older people aging with HIV in the US: a modeling study. AIDS 2024:00002030-990000000-00446. [PMID: 38329107 DOI: 10.1097/qad.0000000000003862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
OBJECTIVE Almost 400 000 people with HIV (PWH) in the United States are over age 55 years and at risk for age-associated dementias (AAD), including Alzheimer's disease and vascular contributions to cognitive impairment and dementia (VCID). We projected the cumulative incidence and mortality associated with AAD among PWH at least 60 years in the United States compared with the general population. DESIGN/METHODS Integrating the CEPAC and AgeD-Pol models, we simulated two cohorts of male and female individuals at least 60 years old: PWH, and general US population. We estimated AAD incidence and AAD-associated mortality rates. Projected outcomes included AAD cumulative incidence, life expectancy, and quality-adjusted life-years (QALYs). We performed sensitivity and scenario analyses on AAD-specific (e.g. incidence) and HIV-specific (e.g. disengagement from HIV care) parameters, as well as premature aging among PWH. RESULTS We projected that 22.1%/16.3% of 60-year-old male individuals/female individuals with HIV would develop AAD by 80 years compared with 15.9%/13.3% of male individuals/female individuals in the general population. Accounting for age-associated and dementia-associated quality of life, 60-year-old PWH would have a lower life expectancy (QALYs): 17.4 years (14.1 QALYs) and 16.8 years (13.4 QALYs) for male and female individuals, respectively, compared with the general population [men, 21.7 years (18.4 QALYs); women, 24.7 years (20.2 QALYs)]. AAD cumulative incidence was most sensitive to non-HIV-related mortality, engagement in HIV care, and AAD incidence rates. CONCLUSION Projected estimates of AAD-associated morbidity, mortality, and quality of life can inform decision-makers and health systems planning as the population of PWH ages. Improved AAD prevention, treatment, and supportive care planning are critical for people aging with HIV.
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Affiliation(s)
- Emily P Hyle
- Medical Practice Evaluation Center, Department of Medicine
- Division of Infectious Diseases, Massachusetts General Hospital
- Harvard Medical School, Boston
- Harvard University Center for AIDS Research, Cambridge
| | | | - Shibani S Mukerji
- Harvard Medical School, Boston
- Department of Neurology, Massachusetts General Hospital, Boston
| | | | - Krishna P Reddy
- Medical Practice Evaluation Center, Department of Medicine
- Harvard Medical School, Boston
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Liyang Yu
- Medical Practice Evaluation Center, Department of Medicine
| | - Anand Viswanathan
- Harvard Medical School, Boston
- Department of Neurology, Massachusetts General Hospital, Boston
| | - Leah H Rubin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore
- Brigham and Women's Hospital
- Johns Hopkins School of Medicine, Baltimore, MD
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Department of Medicine
- Harvard Medical School, Boston
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Department of Medicine
- Division of Infectious Diseases, Massachusetts General Hospital
- Harvard Medical School, Boston
- Harvard University Center for AIDS Research, Cambridge
- Harvard T.H. Chan School of Public Health
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
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3
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Levison JH, Del Cueto P, Mendoza JV, Ashour D, Lydston M, Freedberg KA, Shebl FM. Systematic Review and Meta-analysis of Linkage to HIV Care Interventions in the United States, Canada, and Ukraine (2010-2021). AIDS Behav 2023; 27:4070-4083. [PMID: 37523048 PMCID: PMC10598185 DOI: 10.1007/s10461-023-04121-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 08/01/2023]
Abstract
We conducted a systematic review and meta-analysis of interventions targeting linkage to HIV care in the US, Canada, and Europe. We searched six databases (PubMed, Embase, Cochrane Library, Web of Science and CINAHL). Inclusion criteria were English language studies in adults in the US, Canada, or Europe, published January 1, 2010 to January 1, 2021. We synthesized interventions by type and linkage to care outcome. The outcome was cumulative incidence of 3-month linkage. We estimated cumulative incidence ratios of linkage with 95% confidence intervals (CIs). We screened 945 studies; 13 met selection criteria (n = 1 from Canada, n = 1 from Ukraine, n = 11 from the US) and were included after full text review (total 37,549 individuals). The cumulative incidence of 3-month linkage in the intervention group was 0.82 (95% CI 0.68-0.94) and control group 0.71 (95% CI 0.50-0.90); cIR of linkage for intervention versus control was 1.30 (95% CI 1.13, 1.49). Interventions to improve linkage to care after HIV diagnosis warrant further attention.
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Affiliation(s)
- Julie H Levison
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Paola Del Cueto
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Jaime Vladimir Mendoza
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA
| | - Dina Ashour
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Melis Lydston
- Treadwell Library, Massachusetts General Hospital, Boston, MA, USA
| | - Kenneth A Freedberg
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Fatma M Shebl
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA, 02114, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Pinkney JA, Davis JB, Collins JE, Shebl FM, Jamison MP, Acosta Julbe JI, Bogart LM, Ojikutu BO, Chen AF, Nelson SB. Racial Disparities in Periprosthetic Joint Infections after Primary Total Joint Arthroplasty: A Retrospective Study. Antibiotics (Basel) 2023; 12:1629. [PMID: 37998831 PMCID: PMC10668943 DOI: 10.3390/antibiotics12111629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/05/2023] [Accepted: 11/12/2023] [Indexed: 11/25/2023] Open
Abstract
In the United States, racial disparities have been observed in complications following total joint arthroplasty (TJA), including readmissions and mortality. It is unclear whether such disparities also exist for periprosthetic joint infection (PJI). The clinical data registry of a large New England hospital system was used to identify patients who underwent TJA between January 2018 and December 2021. The comorbidities were evaluated using the Elixhauser Comorbidity Index (ECI). We used Poisson regression to assess the relationship between PJI and race by estimating cumulative incidence ratios (cIRs) and 95% confidence intervals (CIs). We adjusted for age and sex and examined whether ECI was a mediator using structural equation modeling. The final analytic dataset included 10,018 TJAs in 9681 individuals [mean age (SD) 69 (10)]. The majority (96.5%) of the TJAs were performed in non-Hispanic (NH) White individuals. The incidence of PJI was higher among NH Black individuals (3.1%) compared with NH White individuals (1.6%) [adjusted cIR = 2.12, 95%CI = 1.16-3.89; p = 0.015]. Comorbidities significantly mediated the association between race and PJI, accounting for 26% of the total effect of race on PJI incidence. Interventions that increase access to high-quality treatments for comorbidities before and after TJA may reduce racial disparities in PJI.
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Affiliation(s)
- Jodian A. Pinkney
- Massachusetts General Hospital, Boston, MA 02114, USA; (F.M.S.)
- Harvard Medical School, Boston, MA 02115, USA; (J.E.C.)
| | - Joshua B. Davis
- Brigham and Women’s Hospital, Boston, MA 02115, USA; (J.B.D.); (M.P.J.); (J.I.A.J.)
| | - Jamie E. Collins
- Harvard Medical School, Boston, MA 02115, USA; (J.E.C.)
- Brigham and Women’s Hospital, Boston, MA 02115, USA; (J.B.D.); (M.P.J.); (J.I.A.J.)
| | - Fatma M. Shebl
- Massachusetts General Hospital, Boston, MA 02114, USA; (F.M.S.)
| | - Matthew P. Jamison
- Brigham and Women’s Hospital, Boston, MA 02115, USA; (J.B.D.); (M.P.J.); (J.I.A.J.)
| | - Jose I. Acosta Julbe
- Brigham and Women’s Hospital, Boston, MA 02115, USA; (J.B.D.); (M.P.J.); (J.I.A.J.)
| | - Laura M. Bogart
- RAND Corporation, Santa Monica, CA 90401, USA
- Charles R. Drew University of Medicine and Science, Los Angeles, CA 90059, USA
| | - Bisola O. Ojikutu
- Massachusetts General Hospital, Boston, MA 02114, USA; (F.M.S.)
- Harvard Medical School, Boston, MA 02115, USA; (J.E.C.)
- Brigham and Women’s Hospital, Boston, MA 02115, USA; (J.B.D.); (M.P.J.); (J.I.A.J.)
- Boston Public Health Commission, Boston, MA 02118, USA
| | - Antonia F. Chen
- Harvard Medical School, Boston, MA 02115, USA; (J.E.C.)
- Brigham and Women’s Hospital, Boston, MA 02115, USA; (J.B.D.); (M.P.J.); (J.I.A.J.)
| | - Sandra B. Nelson
- Massachusetts General Hospital, Boston, MA 02114, USA; (F.M.S.)
- Harvard Medical School, Boston, MA 02115, USA; (J.E.C.)
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5
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Rich KM, Pandya A, Chiosi JJ, Reddy KP, Shebl FM, Ciaranello AL, Neilan AM, Pinkney JA, Losina E, Freedberg KA, Ahonkhai AA, Hyle EP. Projected Life Expectancy Gains From Improvements in HIV Care in Black and White Men Who Have Sex With Men. JAMA Netw Open 2023; 6:e2344385. [PMID: 38015507 PMCID: PMC10685884 DOI: 10.1001/jamanetworkopen.2023.44385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/12/2023] [Indexed: 11/29/2023] Open
Abstract
Importance Substantial racial inequities exist across the HIV care continuum between non-Hispanic Black and White men who have sex with men (MSM) in the US. Objectives To project years of life gained (YLG) with improving the HIV care continuum among Black MSM and White MSM in the US and to determine the outcomes of achieving health equity goals. Design, Setting, and Participants The Cost-Effectiveness of Preventing AIDS Complications microsimulation model was used and populated with 2021 race-specific data to simulate HIV care among Black MSM and White MSM in the US who have acquired HIV. Analyses were completed from July 2021 to October 2023. Intervention The study simulated status quo care using race-specific estimates: age at infection, time to diagnosis, receipt of care, and virologic suppression. The study next projected the outcomes of attaining equity-centered vs non-equity-centered goals by simulating 2 equal improvements in care goals: (10-point increased receipt of care and 5-point increased virologic suppression), 3 equity-centered goals (annual HIV testing, 95% receiving HIV care, and 95% virologic suppression) and lastly, an equitable care continuum that achieves annual HIV testing, 95% receiving care, and 95% virologic suppression in Black MSM and White MSM. One-way and multiway sensitivity and scenario analyses were conducted. Main Outcomes and Measures Mean age at death and YLG. Results In the simulated cohort, the mean (SD) age at HIV infection was 27.0 (10.8) years for Black MSM and 35.5 (13.6) years for White MSM. In status quo, mean age at death would be 68.8 years for Black MSM and 75.6 years for White MSM. The equal improvements in care goals would result in 0.5 YLG for Black MSM and 0.5 to 0.9 YLG for White MSM. Achieving any 1 equity-centered goal would result in 0.5 to 1.7 YLG for Black MSM and 0.4 to 1.3 YLG for White MSM. With an equitable care continuum compared with the nationally reported status quo, Black MSM and White MSM would gain 3.5 and 2.1 life-years, respectively. If the status quo HIV testing was every 6 years with 75% retained in care and 75% virologically suppressed, Black MSM would gain 4.2 life-years with an equitable care continuum. Conclusions and Relevance In this simulation modeling study of HIV care goals, equal improvements in HIV care for Black and White MSM maintained or worsened inequities. These results suggest that equity-centered goals for the HIV care continuum are critical to mitigate long-standing inequities in HIV outcomes.
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Affiliation(s)
- Katherine M. Rich
- Medical Practice Evaluation Center (MPEC), Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - John J. Chiosi
- Medical Practice Evaluation Center (MPEC), Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
| | - Krishna P. Reddy
- Medical Practice Evaluation Center (MPEC), Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston
| | - Fatma M. Shebl
- Medical Practice Evaluation Center (MPEC), Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Andrea L. Ciaranello
- Medical Practice Evaluation Center (MPEC), Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
| | - Anne M. Neilan
- Medical Practice Evaluation Center (MPEC), Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
- Division of General Academic Pediatrics, Massachusetts General Hospital, Boston
| | - Jodian A. Pinkney
- Medical Practice Evaluation Center (MPEC), Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
| | - Elena Losina
- Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Massachusetts
- Orthopedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Policy and Innovation Evaluation in Orthopedic Treatments (PIVOT) Center, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kenneth A. Freedberg
- Medical Practice Evaluation Center (MPEC), Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts
| | - Aima A. Ahonkhai
- Medical Practice Evaluation Center (MPEC), Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
- Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts
- Department of Medicine, Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily P. Hyle
- Medical Practice Evaluation Center (MPEC), Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
- Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts
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Cunningham SD, Mandelbaum J, Shebl FM, Abraham M, O’Connor Duffany K. Neighborhood Social Environment and Body Mass Index: The Mediating Role of Mental Wellbeing. Int J Environ Res Public Health 2023; 20:6602. [PMID: 37623185 PMCID: PMC10454589 DOI: 10.3390/ijerph20166602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 08/26/2023]
Abstract
The association between neighborhood-built environment and body mass index (BMI) is well-characterized, whereas fewer studies have explored the mechanisms underlying the relationship between neighborhood social environment and obesogenic behaviors. Using data from a random sample of 16,820 residents ≥18 years from all 169 Connecticut towns and seven ZIP Codes in New York, this study examines the influence of neighborhood social environment on residents' mental wellbeing, physical activity, and BMI. Structural equation modeling was conducted to estimate direct and indirect effects of neighborhood social environment on BMI, using mental wellbeing and physical activity as intermediate variables. There were significant total [β(SE) = 0.741 (0.170), p < 0.0001], direct [β(SE) = 0.456 (0.1890), p = 0.016], and indirect [β(SE) = 0.285 (0.061), p < 0.0001] effects of neighborhood social environment on BMI. Low physical activity was a partial mediator of the effect of non-favorable neighborhood social environment on BMI [β(SE) = -0.071 (0.011), p < 0.0001]. The association between neighborhood social environment and BMI was also mediated by mental wellbeing [β(SE) = 0.214 (0.060), p < 0.0001], and by mental wellbeing through physical activity [β(SE) = 0.071 (0.011), p < 0.0001]. Study findings provide further support for building strong social environments to improve population health and suggest that strategies prioritizing mental wellbeing may benefit behavioral interventions aimed at reducing obesity risk and should be a focus of prevention efforts in and of itself.
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Affiliation(s)
- Shayna D. Cunningham
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT 06032, USA;
| | | | - Fatma M. Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA 02114, USA;
- Harvard Medical School, Boston, MA 02115, USA
| | | | - Kathleen O’Connor Duffany
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT 06510, USA
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7
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Shebl FM, Qian Y, Foote JHA, Wattananimitgul N, Reddy KP, Neilan AM, Ciaranello AL, Losina E, Freedberg KA, Hyle EP. The association between all-cause mortality and HIV acquisition risk groups in the United States, 2001-2014. PLoS One 2023; 18:e0290113. [PMID: 37590260 PMCID: PMC10434931 DOI: 10.1371/journal.pone.0290113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/01/2023] [Indexed: 08/19/2023] Open
Abstract
OBJECTIVE To investigate associations between all-cause mortality and human immunodeficiency virus (HIV) acquisition risk groups among people without HIV in the United States. METHODS We used data from 23,657 (NHANES) participants (2001-2014) and the Linked Mortality File to classify individuals without known HIV into HIV acquisition risk groups: people who ever injected drugs (ever-PWID); men who have sex with men (MSM); heterosexually active people at increased risk for HIV (HIH), using low income as a proxy for increased risk. We used Cox proportional hazards models to estimate adjusted and unadjusted all-cause mortality hazard ratios (HR) with 95% confidence intervals (CI). RESULTS Compared with sex-specific heterosexually active people at average risk for HIV (HAH), the adjusted HR (95% CI) were: male ever-PWID 1.67 (1.14, 2.46), female ever-PWID 3.50 (2.04, 6.01), MSM 1.51 (1.00, 2.27), male HIH 1.68 (1.04, 2.06), female HIH 2.35 (1.87, 2.95), and male ever-PWID 1.67 (1.14, 2.46). CONCLUSIONS Most people at increased risk for HIV in the US experience higher all-cause mortality than people at average risk. Strategies addressing social determinants that increase HIV risk should be incorporated into HIV prevention and other health promotion programs.
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Affiliation(s)
- Fatma M. Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Yiqi Qian
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
| | - Julia H. A. Foote
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Nattanicha Wattananimitgul
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
| | - Krishna P. Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Anne M. Neilan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Andrea L. Ciaranello
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Cambridge, Massachusetts, United States of America
| | - Elena Losina
- Harvard University Center for AIDS Research (CFAR), Cambridge, Massachusetts, United States of America
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Cambridge, Massachusetts, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Emily P. Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Cambridge, Massachusetts, United States of America
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8
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Gandhi AR, Hyle EP, Scott JA, Lee JS, Shebl FM, Joska JA, Andersen LS, O'Cleirigh C, Safren SA, Freedberg KA. The Clinical Impact and Cost-Effectiveness of Clinic-Based Cognitive Behavioral Therapy for People With HIV, Depression, and Virologic Failure in South Africa. J Acquir Immune Defic Syndr 2023; 93:333-342. [PMID: 37079899 PMCID: PMC10287047 DOI: 10.1097/qai.0000000000003205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 03/06/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Depression affects 25%-30% of people with HIV (PWH) in the Republic of South Africa (RSA) and is associated with both antiretroviral therapy (ART) nonadherence and increased mortality. We evaluated the cost-effectiveness of task-shifted, cognitive behavioral therapy (CBT) for PWH with diagnosed depression and virologic failure from a randomized trial in RSA. SETTING RSA. METHODS Using the Cost-Effectiveness of Preventing AIDS Complications model, we simulated both trial strategies: enhanced treatment as usual (ETAU) and ETAU plus CBT for ART adherence and depression (CBT-AD; 8 sessions plus 2 follow-ups). In the trial, viral suppression at 1 year was 20% with ETAU and 32% with CBT-AD. Model inputs included mean initial age (39 years) and CD4 count (214/μL), ART costs ($7.5-22/mo), and CBT costs ($29/session). We projected 5- and 10-year viral suppression, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs: $/QALY [discounted 3%/yr]; cost-effectiveness threshold: ≤$2545/QALY [0.5× per capita GDP]). In sensitivity analyses, we determined how input parameter variation affected cost-effectiveness. RESULTS Model-projected 5- and 10-year viral suppression were 18.9% and 8.7% with ETAU and 21.2% and 9.7% with CBT-AD, respectively. Compared with ETAU, CBT-AD would increase discounted life expectancy from 4.12 to 4.68 QALYs and costs from $6210/person to $6670/person (incremental cost-effectiveness ratio: $840/QALY). CBT-AD would remain cost-effective unless CBT-AD cost >$70/session and simultaneously improved 1-year viral suppression by ≤4% compared with ETAU. CONCLUSIONS CBT for PWH with depression and virologic failure in RSA could improve life expectancy and be cost-effective. Such targeted mental health interventions should be integrated into HIV care.
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Affiliation(s)
- Aditya R. Gandhi
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Emily P. Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Center for AIDS Research, Harvard University, Cambridge, MA
| | - Justine A. Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Jasper S. Lee
- Harvard Medical School, Boston, MA
- Department of Psychology, University of Miami, Miami, FL
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Fatma M. Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - John A. Joska
- HIV Mental Health Research Unit, Department of Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Lena S. Andersen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; and
| | - Conall O'Cleirigh
- Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | | | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Center for AIDS Research, Harvard University, Cambridge, MA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
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9
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Gupta A, Ashour D, Shebl FM, Platt L, Chiosi JJ, Nelson SB, Ard KL, Kim AY, Bassett IV. Evaluation of Hepatitis C Treatment Outcomes Among Patients Enrolled in Outpatient Parenteral Antibiotic Therapy-Boston, Massachusetts, 2016-2021. Open Forum Infect Dis 2023; 10:ofad342. [PMID: 37496604 PMCID: PMC10368317 DOI: 10.1093/ofid/ofad342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/03/2023] [Indexed: 07/28/2023] Open
Abstract
In our Boston-based outpatient parenteral antibiotic therapy (OPAT) program between 2016 and 2021, we found that a low proportion of patients with active hepatitis C virus (HCV) were prescribed HCV treatment by their OPAT provider and few achieved sustained virologic response. Clinicians should consider concurrent HCV treatment during OPAT.
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Affiliation(s)
- Akash Gupta
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dina Ashour
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Laura Platt
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - John J Chiosi
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sandra B Nelson
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kevin L Ard
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Arthur Y Kim
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ingrid V Bassett
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
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10
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Luz PM, Deshpande V, Kazemian P, Scott JA, Shebl FM, Spaeth H, Pimenta C, Stern M, Pereira G, Struchiner CJ, Grinsztejn B, Veloso VG, Freedberg KA. Impact of pre-exposure prophylaxis uptake among gay, bisexual, and other men who have sex with men in urban centers in Brazil: a modeling study. BMC Public Health 2023; 23:1128. [PMID: 37308858 PMCID: PMC10262537 DOI: 10.1186/s12889-023-15994-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 05/23/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Men who have sex with men (MSM) in Brazil remain disproportionately affected by HIV. We estimated the potential incidence reduction by five years with increased uptake of publicly-funded, daily, oral tenofovir/emtricitabine (TDF/FTC) for HIV pre-exposure prophylaxis (PrEP) among MSM using the Cost Effectiveness of Preventing AIDS Complications microsimulation model. We used national data, local studies, and literature to inform model parameters for three cities: Rio de Janeiro, Salvador, and Manaus. RESULTS In Rio de Janero, a PrEP intervention achieving 10% uptake within 60 months would decrease incidence by 2.3% whereas achieving 60% uptake within 24 months would decrease incidence by 29.7%; results were similar for Salvador and Manaus. In sensitivity analyses, decreasing mean age at PrEP initiation from 33 to 21 years increased incidence reduction by 34%; a discontinuation rate of 25% per year decreased it by 12%. CONCLUSION Targeting PrEP to young MSM and minimizing discontinuation could substantially increase PrEP's impact.
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Affiliation(s)
- Paula M Luz
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Avenida Brasil 4365, Rio de Janeiro, 21040-360, Brazil.
| | - Vijeta Deshpande
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Pooyan Kazemian
- Department of Operations, Weatherhead School of Management, Case Western Reserve University, 11119 Bellflower Road, Cleveland, OH, 44106, USA
| | - Justine A Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Hailey Spaeth
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Cristina Pimenta
- Ministry of Health of Brazil, SRTVN Quadra 701, Lote D, Edifício PO700, 5º Andar, Brasília/DFBrasilia, 70719-040, Brazil
| | - Madeline Stern
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
| | - Gerson Pereira
- Ministry of Health of Brazil, SRTVN Quadra 701, Lote D, Edifício PO700, 5º Andar, Brasília/DFBrasilia, 70719-040, Brazil
| | | | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Avenida Brasil 4365, Rio de Janeiro, 21040-360, Brazil
| | - Valdilea G Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Avenida Brasil 4365, Rio de Janeiro, 21040-360, Brazil
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge Street, Suite 1684, Boston, MA, 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
- Harvard University Center for AIDS Research, Harvard Medical School, 42 Church Street, Cambridge, MA, 02138, USA
- Division of General Internal Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
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11
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Pinkney JA, Bogart LM, Carroll KN, Bryan L, Witter G, Ashour D, Shebl FM, Hurtado RM, Goldfarb IT, Hyle EP, Psaros C, Ojikutu BO. Factors Associated With Coronavirus Disease 2019 Vaccine Uptake Among Pregnant Women and Nonpregnant Women of Reproductive Age in Jamaica. Open Forum Infect Dis 2023; 10:ofad201. [PMID: 37234512 PMCID: PMC10208745 DOI: 10.1093/ofid/ofad201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/10/2023] [Indexed: 05/28/2023] Open
Abstract
Background Despite high rates of coronavirus disease 2019 (COVID-19)-related maternal mortality, Jamaica currently has little data on COVID-19 vaccine uptake among pregnant women. Methods We conducted a cross-sectional, web-based survey of 192 reproductive-aged women in Jamaica from February 1 to 8, 2022. Participants were recruited from a convenience sample of patients, providers, and staff at a teaching hospital. We assessed self-reported COVID-19 vaccination status and COVID-19-related medical mistrust (operationalized as vaccine confidence, government mistrust, and race-based mistrust). We used multivariable modified Poisson regression to test the association between vaccine uptake and pregnancy. Results Of 192 respondents, 72 (38%) were pregnant. Most (93%) were Black. Vaccine uptake was 35% in pregnant women versus 75% in nonpregnant women. Pregnant women were more likely to cite healthcare providers versus the government as trustworthy sources of COVID-19 vaccine information (65% vs 28%). Pregnancy, low vaccine confidence, and government mistrust were associated with a lower likelihood of COVID-19 vaccination (adjusted prevalence ratio [aPR] = 0.68 [95% confidence interval {CI}, .49-.95], aPR = 0.61 [95% CI, .40-.95], and aPR = 0.68 [95% CI, .52-.89], respectively). Race-based mistrust was not associated with COVID-19 vaccination in the final model. Conclusions Pregnancy, low vaccine confidence, and government mistrust were associated with a lower likelihood of COVID-19 vaccination among reproductive-aged women in Jamaica. Future studies should evaluate the efficacy of strategies proven to improve maternal vaccination coverage, including standing "opt-out" vaccination orders and collaborative provider and patient-led educational videos tailored for pregnant individuals. Strategies that decouple vaccine messaging from government agencies also warrant evaluation.
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Affiliation(s)
- Jodian A Pinkney
- Correspondence: Jodian A. Pinkney, MD, Massachusetts General Hospital, 55 Fruit Street, Cox 5, Boston, MA 02114 (); Laura Bogart, PhD, RAND Corporation, 1776 Main Street, Santa Monica, CA ()
| | - Laura M Bogart
- Correspondence: Jodian A. Pinkney, MD, Massachusetts General Hospital, 55 Fruit Street, Cox 5, Boston, MA 02114 (); Laura Bogart, PhD, RAND Corporation, 1776 Main Street, Santa Monica, CA ()
| | | | - Lenroy Bryan
- University of the West Indies, Kingston, Jamaica
| | | | - Dina Ashour
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Rocio M Hurtado
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ilona T Goldfarb
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emily P Hyle
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Christina Psaros
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
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12
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Hyle EP, Kasaie P, Schwamm E, Stewart C, Humes E, Reddy KP, Rebeiro PF, Stanic T, Pei PP, Gerace L, Ang L, Gebo KA, Yu L, Shebl FM, Freedberg KA, Althoff KN. A Growing Number of Men Who Have Sex With Men Aging With HIV (20212031): A Comparison of Two Microsimulation Models. J Infect Dis 2023; 227:412-422. [PMID: 36478076 PMCID: PMC10169437 DOI: 10.1093/infdis/jiac473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/23/2022] [Accepted: 12/06/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Men who have sex with men (MSM) on antiretroviral therapy (ART) are at risk for multimorbidity as life expectancy increases. Simulation models can project population sizes and age distributions to assist with health policy planning. METHODS We populated the CEPAC-US model with CDC data to project the HIV epidemic among MSM in the United States. The PEARL model was predominantly informed by NA-ACCORD data (20092017). We compared projected population sizes and age distributions of MSM receiving ART (20212031) and investigated how parameters and assumptions affected results. RESULTS We projected an aging and increasing population of MSM on ART: CEPAC-US, mean age 48.6 (SD 13.7) years in 2021 versus 53.9 (SD 15.0) years in 2031; PEARL, 46.7 (SD 13.2) years versus 49.2 (SD 14.6) years. We projected 548 800 MSM on ART (147 020 65 years) in 2031 (CEPAC-US) and 599 410 (113 400 65 years) (PEARL). Compared with PEARL, CEPAC-US projected a smaller population of MSM on ART by 2031 and a slower increase in population size, driven by higher estimates of disengagement in care and mortality. CONCLUSIONS Findings from two structurally distinct microsimulation models suggest that the MSM population receiving ART in the United States will increase and age over the next decade. Subgroup-specific data regarding engagement in care and mortality can improve projections and inform health care policy planning.
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Affiliation(s)
- Emily P Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard University Center for AIDS Research, Boston, Massachusetts, USA
| | - Parastu Kasaie
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Eli Schwamm
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Cameron Stewart
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth Humes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Krishna P Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter F Rebeiro
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Tijana Stanic
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pamela P Pei
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lucas Gerace
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Luke Ang
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kelly A Gebo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Liyang Yu
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard University Center for AIDS Research, Boston, Massachusetts, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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13
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Resch SC, Foote JHA, Wirth KE, Lasry A, Scott JA, Moore J, Shebl FM, Gaolathe T, Feser MK, Lebelonyane R, Hyle EP, Mmalane MO, Bachanas P, Yu L, Makhema JM, Holme MP, Essex M, Alwano MG, Lockman S, Freedberg KA. Health Impact and Cost-Effectiveness of HIV Testing, Linkage, and Early Antiretroviral Treatment in the Botswana Combination Prevention Project. J Acquir Immune Defic Syndr 2022; 90:399-407. [PMID: 35420554 PMCID: PMC9295776 DOI: 10.1097/qai.0000000000002996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Botswana Combination Prevention Project tested the impact of combination prevention (CP) on HIV incidence in a community-randomized trial. Each trial arm had ∼55,000 people, 26% HIV prevalence, and 72% baseline ART coverage. Results showed intensive testing and linkage campaigns, expanded antiretroviral treatment (ART), and voluntary male medical circumcision referrals increased coverage and decreased incidence over ∼29 months of follow-up. We projected lifetime clinical impact and cost-effectiveness of CP in this population. SETTING Rural and periurban communities in Botswana. METHODS We used the Cost-Effectiveness of Preventing AIDS Complications model to estimate lifetime health impact and cost of (1) earlier ART initiation and (2) averting an HIV infection, which we applied to incremental ART initiations and averted infections calculated from trial data. We determined the incremental cost-effectiveness ratio [US$/quality-adjusted life-years (QALY)] for CP vs. standard of care. RESULTS In CP, 1418 additional people with HIV initiated ART and an additional 304 infections were averted. For each additional person started on ART, life expectancy increased 0.90 QALYs and care costs increased by $869. For each infection averted, life expectancy increased 2.43 QALYs with $9200 in care costs saved. With CP, an additional $1.7 million were spent on prevention and $1.2 million on earlier treatment. These costs were mostly offset by decreased care costs from averted infections, resulting in an incremental cost-effectiveness ratio of $79 per QALY. CONCLUSIONS Enhanced HIV testing, linkage, and early ART initiation improve life expectancy, reduce transmission, and can be cost-effective or cost-saving in settings like Botswana.
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Affiliation(s)
- Stephen C. Resch
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Kresge 3 & 4 Floors, Boston, MA 02115, USA
| | - Julia H. A. Foote
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
| | - Kathleen E. Wirth
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, 651 Huntington Avenue, Boston, MA 02115, USA
| | - Arielle Lasry
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, USA
| | - Justine A. Scott
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
| | - Janet Moore
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, USA
| | - Fatma M. Shebl
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Tendani Gaolathe
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
| | - Mary K. Feser
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
| | - Refeletswe Lebelonyane
- Botswana Ministry of Health and Wellness, Plot 54609, 24 Amos Street, Government Enclave, Gaborone, Botswana
| | - Emily P. Hyle
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02144, USA
- Harvard University Center for AIDS Research, 42 Church Street, Cambridge, MA 02138, USA
| | - Mompati O. Mmalane
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
| | - Pamela Bachanas
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, USA
| | - Liyang Yu
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
| | - Joseph M. Makhema
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
| | - Molly Pretorius Holme
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, 651 Huntington Avenue, Boston, MA 02115, USA
| | - Max Essex
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, 651 Huntington Avenue, Boston, MA 02115, USA
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
| | | | - Shahin Lockman
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, 651 Huntington Avenue, Boston, MA 02115, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Botswana-Harvard AIDS Institute Partnership, Princess Marina Hospital, Plot No. 1836, Northring Road, Gaborone, Botswana
- Division of Infectious Diseases, Brigham and Women’s Hospital, 45 Francis Street, 2 Floor, Boston, MA 02115, USA
| | - Kenneth A. Freedberg
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Kresge 3 & 4 Floors, Boston, MA 02115, USA
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02144, USA
- Harvard University Center for AIDS Research, 42 Church Street, Cambridge, MA 02138, USA
- Division of General Internal Medicine, Massachusetts General Hospital, 50 Staniford Street, 9 Floor, Boston, MA 02114, USA
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14
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Hyle EP, Foote JHA, Shebl FM, Qian Y, Reddy KP, Mukerji SS, Wattananimitgul N, Viswanathan A, Schwamm LH, Pandya A, Freedberg KA. Development and validation of the age-associated dementia policy (AgeD-Pol) computer simulation model in the USA and Europe. BMJ Open 2022; 12:e056546. [PMID: 35793913 PMCID: PMC9260808 DOI: 10.1136/bmjopen-2021-056546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE To develop and validate a novel, microsimulation model that accounts for the prevalence and incidence of age-associated dementias (AAD), disease progression and associated mortality. DESIGN, DATA SOURCES AND OUTCOME MEASURES We developed the AAD policy (AgeD-Pol) model, a microsimulation model to simulate the natural history, morbidity and mortality associated with AAD. We populated the model with age-stratified and sex-stratified data on AAD prevalence, AAD incidence and mortality among people with AAD. We first performed internal validation using data from the Adult Changes in Thought (ACT) cohort study. We then performed external validation of the model using data from the Framingham Heart Study, the Rotterdam Study and Kaiser Permanente Northern California (KPNC). We compared model-projected AAD cumulative incidence and mortality with published cohort data using mean absolute percentage error (MAPE) and root-mean-square error (RMSE). RESULTS In internal validation, the AgeD-Pol model provided a good fit to the ACT cohort for cumulative AAD incidence, 10.4% (MAPE, 0.2%) and survival, 66.5% (MAPE, 8.8%), after 16 years of follow-up among those initially aged 65-69 years. In the external validations, the model-projected lifetime cumulative incidence of AAD was 30.5%-32.4% (females) and 16.7%-23.0% (males), using data from the Framingham and Rotterdam cohorts, and AAD cumulative incidence was 21.5% over 14 years using KPNC data. Model projections demonstrated a good fit to all three cohorts (MAPE, 0.9%-9.0%). Similarly, model-projected survival provided good fit to the Rotterdam (RMSE, 1.9-3.6 among those with and without AAD) and KPNC cohorts (RMSE, 7.6-18.0 among those with AAD). CONCLUSIONS The AgeD-Pol model performed well when validated to published data for AAD cumulative incidence and mortality and provides a useful tool to project the AAD disease burden for health systems planning in the USA.
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Affiliation(s)
- Emily P Hyle
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard University Center for AIDS Research, Cambridge, Massachusetts, USA
| | - Julia H A Foote
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Yiqi Qian
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Krishna P Reddy
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shibani S Mukerji
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nattanicha Wattananimitgul
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anand Viswanathan
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lee H Schwamm
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ankur Pandya
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard University Center for AIDS Research, Cambridge, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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15
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Siedner MJ, Alba C, Fitzmaurice KP, Gilbert RF, Scott JA, Shebl FM, Ciaranello A, Reddy KP, Freedberg KA. Cost-effectiveness of Coronavirus Disease 2019 Vaccination in Low- and Middle-Income Countries. J Infect Dis 2022; 226:1887-1896. [PMID: 35696544 PMCID: PMC9214172 DOI: 10.1093/infdis/jiac243] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 06/10/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Despite the advent of safe and effective coronavirus disease 2019 vaccines, pervasive inequities in global vaccination persist. METHODS We projected health benefits and donor costs of delivering vaccines for up to 60% of the population in 91 low- and middle-income countries (LMICs). We modeled a highly contagious (Re at model start, 1.7), low-virulence (infection fatality ratio [IFR], 0.32%) "Omicron-like" variant and a similarly contagious "severe" variant (IFR, 0.59%) over 360 days, accounting for country-specific age structure and healthcare capacity. Costs included vaccination startup (US$630 million) and per-person procurement and delivery (US$12.46/person vaccinated). RESULTS In the Omicron-like scenario, increasing current vaccination coverage to achieve at least 15% in each of the 91 LMICs would prevent 11 million new infections and 120 000 deaths, at a cost of US$0.95 billion, for an incremental cost-effectiveness ratio (ICER) of US$670/year of life saved (YLS). Increases in vaccination coverage to 60% would additionally prevent up to 68 million infections and 160 000 deaths, with ICERs <US$8000/YLS. ICERs were <US$4000/YLS under the more severe variant scenario and generally robust to assumptions about vaccine effectiveness, uptake, and costs. CONCLUSIONS Funding expanded COVID-19 vaccine delivery in LMICs would save hundreds of thousands of lives, be similarly or more cost-effective than other donor-funded global aid programs, and improve health equity.
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Affiliation(s)
- Mark J. Siedner
- Corresponding Author: Mark J. Siedner, MD MPH Medical Practice Evaluation Center, Massachusetts General Hospital 100 Cambridge Street, Suite 1600, Boston, MA 02114, USA Fax: 617-724-1637 Telephone: 617-726-4686
| | - Christopher Alba
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Rebecca F. Gilbert
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Justine A. Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Fatma M. Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Andrea Ciaranello
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Harvard University Center for AIDS Research, Cambridge, MA, USA
| | - Krishna P. Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kenneth A. Freedberg
- Alternate Corresponding Author: Kenneth A. Freedberg, MD, MSc Medical Practice Evaluation Center, Massachusetts General Hospital 100 Cambridge Street, Suite 1600, Boston, MA 02114, USA Fax: 617-726-6063
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16
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Neilan AM, Tyagi A, Tong Y, Farkas EJ, Burns MD, Fialkowski A, Park G, Hardcastle M, Gootkind E, Bassett IV, Shebl FM, Yonker LM. Pediatric biorepository participation during the COVID-19 pandemic: predictors of enrollment and biospecimen donation. BMC Pediatr 2022; 22:130. [PMID: 35279115 PMCID: PMC8917327 DOI: 10.1186/s12887-022-03185-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/03/2022] [Indexed: 11/21/2022] Open
Abstract
Background Patient-level predictors of enrollment in pediatric biorepositories are poorly described. Especially in pandemic settings, understanding who is likely to enroll in a biorepository is critical to interpreting analyses conducted on biospecimens. We describe predictors of pediatric COVID-19 biorepository enrollment and biospecimen donation to identify gaps in COVID-19 research on pediatric biospecimens. Methods We compared data from enrollees and non-enrollees aged 0–25 years with suspected or confirmed COVID-19 infection who were approached for enrollment in the Massachusetts General Hospital pediatric COVID-19 biorepository between April 12, 2020, and May 28, 2020, from community or academic outpatient or inpatient settings. Demographic and clinical data at presentation to care were from automatic and manual chart extractions. Predictors of enrollment and biospecimen donation were assessed with Poisson regression models. Results Among 457 individuals approached, 214 (47%) enrolled in the biorepository. A COVID-19 epidemiologic risk factor was recorded for 53%, and 15% lived in a US Centers for Disease Control and Prevention-defined COVID-19 hotspot. Individuals living in a COVID-19 hotspot (relative risk (RR) 2.4 [95% confidence interval (CI): 1.8–3.2]), with symptoms at presentation (RR 1.8 [95% CI: 1.2–2.7]), or admitted to hospital (RR 1.8 [95% CI: 1.2–2.8]) were more likely to enroll. Seventy-nine percent of enrollees donated any biospecimen, including 97 nasopharyngeal swabs, 119 oropharyngeal swabs, and 105 blood, 16 urine, and 16 stool specimens, respectively. Age, sex, race, ethnicity, and neighborhood-level socioeconomic status based on zip code did not predict enrollment or biospecimen donation. Conclusions While fewer than half of individuals approached consented to participate in the pediatric biorepository, enrollment appeared to be representative of children affected by the pandemic. Living in a COVID-19 hotspot, symptoms at presentation to care and hospital admission predicted biorepository enrollment. Once enrolled, most individuals donated a biospecimen. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03185-6.
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17
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Gupta A, Shebl FM, Tong Y, Wagner K, Bassett IV, Page K, Winstanley EL. Association of co-occurring mental health problems with hepatitis C status among young people who inject drugs in rural New Mexico, 2016-2018. Addict Sci Clin Pract 2022; 17:58. [PMID: 36266666 PMCID: PMC9583516 DOI: 10.1186/s13722-022-00340-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 09/28/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Injection drug use (IDU) remains the strongest risk factor for hepatitis C virus (HCV) in the United States. HCV rates are increasing in rural areas among young adult people who inject drugs (PWID). People with HCV and PWID have disproportionate rates of mental health problems; however, it is unclear whether risky injection behaviors mediate the association between mental health problems and HCV. We examined the association between mental health problems and HCV in a rural cohort of young adult PWID, with the goal of informing rural service delivery. METHODS We conducted a secondary analysis of cross-sectional data from a convenience sample of young adult PWID in 2 rural counties in New Mexico. Participants were recruited from 2 community venues between September 2016 and May 2018. Associations between mental health problems and HCV were examined using bivariate (Fisher's exact) and multivariable modified Poisson regression analyses (with robust standard errors). Using structural equation modeling (SEM), we assessed duration of IDU and receptive syringe sharing (RSS) as mediators of this relationship. RESULTS A total of 263 patients were enrolled, with a median age of 26.1 years. The majority were male (66.3%) and Hispanic/Latino (a) (87.6%). The median age first injected was 19 years, and over half reported having ever engaged in RSS (53.4%). At least one mental health problem was reported by 60.1% of participants, with post-traumatic stress disorder (PTSD) being the most prevalent condition (42.2%). A majority (60.9%) tested positive for HCV antibody, and just under half (45.7%) of all participants tested positive for HCV ribonucleic acid. In SEM, PTSD had a significant total effect on HCV (τ = 0.230, P = 0.05), and this relationship was partially mediated by duration of IDU (αβ = 0.077, P = 0.03). The association between mental health problems and HCV was partially mediated by duration of IDU and the sequential mediation of duration of IDU and RSS (αβ + αββ = 0.091, P = 0.05). CONCLUSIONS High HCV rates among young adult PWID in rural New Mexico may be partly explained by mental health problems, duration of IDU and RSS. Mental health services for young adult PWID in rural areas may help decrease HCV transmission in rural areas. Trial Registration N/A.
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Affiliation(s)
- Akash Gupta
- Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA, 02114, USA.
| | - Fatma M. Shebl
- grid.32224.350000 0004 0386 9924Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114 USA
| | - Yao Tong
- grid.32224.350000 0004 0386 9924Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114 USA
| | - Katherine Wagner
- grid.266832.b0000 0001 2188 8502University of New Mexico, Albuquerque, NM USA
| | - Ingrid V. Bassett
- grid.32224.350000 0004 0386 9924Medical Practice Evaluation Center, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114 USA
| | - Kimberly Page
- grid.266832.b0000 0001 2188 8502University of New Mexico, Albuquerque, NM USA
| | - Erin L. Winstanley
- grid.268154.c0000 0001 2156 6140West Virginia University, Morgantown, WV USA
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18
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Park C, Nam S, Redeker NS, Shebl FM, Dixon J, Jung TH, Whittemore R. The effects of acculturation and environment on lifestyle behaviors in Korean immigrants: the mediating role of acculturative stress and body image discrepancy. Ethn Health 2022; 27:157-173. [PMID: 31535571 DOI: 10.1080/13557858.2019.1658182] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 07/30/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Despite high rates of cardiometabolic diseases in Korean immigrants (KIs), little is known about cultural and environmental factors contributing to lifestyle behaviors. The purpose of this cross-sectional study was to examine the relationships among acculturation, environment, and lifestyle behaviors (dietary behavior, physical activity, and sedentary behavior) through culturally sensitive psychological mediators, body image discrepancy and acculturative stress in middle-aged KIs. DESIGN A cross-sectional study was conducted. KIs aged 30-65 years were recruited online and at Korean community centers and churches in the Northeastern US Participants completed validated measures of dietary behavior (the Nutrition Subscale of the Health Promoting Lifestyle Profile (HPLP) II), physical activity (the International Physical Activity Questionnaire (IPAQ) - short form), and sedentary behavior (the Sedentary Behavior Questionnaire). Acculturative stress was measured by the Acculturative Stress Index and body image discrepancy was measured by the Stunkard Figure Rating Scale. Acculturation was defined as a latent variable measured by Korean and American orientation (Vancouver Index of Acculturation), age of immigration to the US, length of residency in the US, and English proficiency. Data were analyzed with structural equation modeling (SEM). RESULTS The sample included 361 KIs (mean age = 41.77 ± 10.28 years, 48.1% female, and 46.4% overweight or obese). In the SEM model, acculturation had significant indirect effects on dietary behavior, physical activity, and sedentary behavior through body image discrepancy. Acculturative stress mediated the relationship between acculturation and sedentary behavior. Greater environmental support for physical activity and better healthy food accessibility were related to higher levels of physical activity and healthier dietary behavior, respectively. CONCLUSION In our study, acculturation and environmental support for physical activity and healthy food simultaneously influenced KIs' lifestyle behaviors. Addressing an unhealthy body image and acculturative stress may be additional strategies for lifestyle intervention programs to prevent cardiometabolic diseases in KIs.
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Affiliation(s)
- Chorong Park
- School of Nursing, Vanderbilt University, Nashville, TN, USA
- School of Nursing, Yale University, Orange, CT, USA
| | - Soohyun Nam
- School of Nursing, Yale University, Orange, CT, USA
| | | | - Fatma M Shebl
- School of Public Health, Yale University, New Haven, CT, USA
| | - Jane Dixon
- School of Nursing, Yale University, Orange, CT, USA
| | - Tae Hyun Jung
- Department of Biostatistics, School of Public Health, Yale University, New Haven, CT, USA
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19
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Reddy KP, Fitzmaurice KP, Scott JA, Harling G, Lessells RJ, Panella C, Shebl FM, Freedberg KA, Siedner MJ. Clinical outcomes and cost-effectiveness of COVID-19 vaccination in South Africa. medRxiv 2021:2021.05.07.21256852. [PMID: 34013291 PMCID: PMC8132265 DOI: 10.1101/2021.05.07.21256852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Low- and middle-income countries are implementing COVID-19 vaccination strategies in light of varying vaccine efficacies and costs, supply shortages, and resource constraints. Here, we use a microsimulation model to evaluate clinical outcomes and cost-effectiveness of a COVID-19 vaccination program in South Africa. We varied vaccination coverage, pace, acceptance, effectiveness, and cost as well as epidemic dynamics. Providing vaccines to at least 40% of the population and prioritizing vaccine rollout prevented >9 million infections and >73,000 deaths and reduced costs due to fewer hospitalizations. Model results were most sensitive to assumptions about epidemic growth and prevalence of prior immunity to SARS-CoV-2, though the vaccination program still provided high value and decreased both deaths and health care costs across a wide range of assumptions. Vaccination program implementation factors, including prompt procurement, distribution, and rollout, are likely more influential than characteristics of the vaccine itself in maximizing public health benefits and economic efficiency.
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Affiliation(s)
- Krishna P. Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Justine A. Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Guy Harling
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, South Africa
- School of Nursing & Public Health, College of Health Sciences, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, UK
- Department of Epidemiology and Harvard Center for Population & Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Richard J. Lessells
- KwaZulu-Natal Research Innovation and Sequencing (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Christopher Panella
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Fatma M. Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mark J. Siedner
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
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20
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Neilan AM, Losina E, Bangs AC, Flanagan C, Panella C, Eskibozkurt GE, Mohareb A, Hyle EP, Scott JA, Weinstein MC, Siedner MJ, Reddy KP, Harling G, Freedberg KA, Shebl FM, Kazemian P, Ciaranello AL. Clinical Impact, Costs, and Cost-effectiveness of Expanded Severe Acute Respiratory Syndrome Coronavirus 2 Testing in Massachusetts. Clin Infect Dis 2021; 73:e2908-e2917. [PMID: 32945845 PMCID: PMC7543346 DOI: 10.1093/cid/ciaa1418] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND We projected the clinical and economic impact of alternative testing strategies on coronavirus disease 2019 (COVID-19) incidence and mortality in Massachusetts using a microsimulation model. METHODS We compared 4 testing strategies: (1) hospitalized: polymerase chain reaction (PCR) testing only for patients with severe/critical symptoms warranting hospitalization; (2) symptomatic: PCR for any COVID-19-consistent symptoms, with self-isolation if positive; (3) symptomatic + asymptomatic once: symptomatic and 1-time PCR for the entire population; and (4) symptomatic + asymptomatic monthly: symptomatic with monthly retesting for the entire population. We examined effective reproduction numbers (Re = 0.9-2.0) at which policy conclusions would change. We assumed homogeneous mixing among the Massachusetts population (excluding those residing in long-term care facilities). We used published data on disease progression and mortality, transmission, PCR sensitivity/specificity (70%/100%), and costs. Model-projected outcomes included infections, deaths, tests performed, hospital-days, and costs over 180 days, as well as incremental cost-effectiveness ratios (ICERs, $/quality-adjusted life-year [QALY]). RESULTS At Re = 0.9, symptomatic + asymptomatic monthly vs hospitalized resulted in a 64% reduction in infections and a 46% reduction in deaths, but required >66-fold more tests/day with 5-fold higher costs. Symptomatic + asymptomatic monthly had an ICER <$100 000/QALY only when Re ≥1.6; when test cost was ≤$3, every 14-day testing was cost-effective at all Re examined. CONCLUSIONS Testing people with any COVID-19-consistent symptoms would be cost-saving compared to testing only those whose symptoms warrant hospital care. Expanding PCR testing to asymptomatic people would decrease infections, deaths, and hospitalizations. Despite modest sensitivity, low-cost, repeat screening of the entire population could be cost-effective in all epidemic settings.
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Affiliation(s)
- Anne M Neilan
- Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Elena Losina
- Harvard Medical School, Boston, Massachusetts, USA
- Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Policy and Innovation eValuation in Orthopedic Treatments Center, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Audrey C Bangs
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Clare Flanagan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher Panella
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - G Ege Eskibozkurt
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amir Mohareb
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Emily P Hyle
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard University Center for AIDS Research, Cambridge, Massachusetts, USA
| | - Justine A Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Milton C Weinstein
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Mark J Siedner
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Krishna P Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Guy Harling
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Institute for Global Health, University College London, London, United Kingdom
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
| | - Kenneth A Freedberg
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Pooyan Kazemian
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea L Ciaranello
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard University Center for AIDS Research, Cambridge, Massachusetts, USA
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21
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Orr L, Shebl FM, Heimer R, Khoshnood K, Barbour R, Khouri D, Aaraj E, Mokhbat JE, Crawford FW. Violence and Discrimination Against Men Who Have Sex With Men in Lebanon: The Role of International Displacement and Migration. J Interpers Violence 2021; 36:10267-10284. [PMID: 31658847 DOI: 10.1177/0886260519884684] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Homosexuality is illegal in Lebanon and men who have sex with men (MSM) may experience discrimination. Displaced Syrians, who currently comprise approximately 20% of Lebanon's population, also face discrimination. Individuals who are members of both groups may experience heightened levels of discrimination and abuse. In partnership with local nongovernmental organizations serving the community, we recruited N = 292 MSM in Beirut, Lebanon. Participants were interviewed about experiences of violence and discrimination in the context of a larger health behavior survey, and all were offered anonymous HIV testing. Responses were analyzed using the framework of intersectionality, combining regression, geographical mapping of reported experiences, and network analysis of the participant recruitment pattern. MSM, born outside of Lebanon, who are primarily from Syria, face higher levels of discrimination and violence than native-born MSM (71% vs. 32% reporting at least one type of discrimination or violence). Socioeconomic status is also associated with discrimination and violence overall, and among native- and foreign-born MSM. Experiences vary by town and neighborhood, and are highly correlated between recruiting and recruited participants.These results highlight health risks faced by foreign-born MSM in Lebanon.
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Affiliation(s)
| | - Fatma M Shebl
- Yale School of Public Health, New Haven, CT, USA
- Harvard Medical School, Boston, MA, USA
| | - Robert Heimer
- Yale University, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Kaveh Khoshnood
- Yale University, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Russell Barbour
- Yale University, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Danielle Khouri
- Independent Contractor and Public Health Consultant, Beirut, Lebanon
| | - Elie Aaraj
- Middle East and North Africa Harm Reduction Association, Beirut, Lebanon
| | | | - Forrest W Crawford
- Yale University, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
- Yale School of Management, New Haven, CT, USA
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22
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Platt L, Shebl FM, Qian Y, Bunda B, Ard KL, Bassett IV. Urban Sexual Health Clinic Patients With "Undetermined Risk" for HIV Are Less Likely to Receive Preexposure Prophylaxis. Sex Transm Dis 2021; 48:881-886. [PMID: 33938518 PMCID: PMC8505145 DOI: 10.1097/olq.0000000000001460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/16/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND New diagnoses of HIV increasingly occur among people who fall outside traditional transmission risk categories. This group remains poorly defined, and HIV prevention efforts for this group lag behind efforts for patients in other risk groups. METHODS We conducted a retrospective review of patient visits at sexual health clinics in Boston, MA, over a 14-month period. Patients were classified into Centers for Disease Control and Prevention-defined HIV transmission risk categories. We compared frequencies of sexually transmitted infections (STIs), HIV, preexposure prophylaxis (PrEP) indications, and PrEP prescriptions. Predictors of HIV or STI among patients in the undetermined risk category were assessed with logistic regression. RESULTS There were 4723 clinic visits during the study period. Patients in the undetermined risk group constituted the largest proportion (55.8%), followed by men who have sex with men (MSM; 42.7%). The proportion of visits by patients in the undetermined risk group with an indication for PrEP was low (28.0%) compared with MSM (91.3%) and MSM who also inject drugs (93.8%); however, the absolute number was high (737). Among patients with an indication for PrEP, those in the undetermined risk group were least likely to receive a prescription. Behavioral risk factors were poorly predictive of STI or HIV among patients in the undetermined risk group. CONCLUSIONS Patients with undetermined risk for HIV constituted a large proportion of clinic visits and had a large volume of sexual health needs but rarely received PrEP when indicated. To end the HIV epidemic in the United States, prevention efforts must include people who fall outside traditional risk categories.
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Affiliation(s)
- Laura Platt
- From the Division of Infectious Diseases
- Medical Practice Evaluation Center, Massachusetts General Hospital
| | - Fatma M. Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital
| | - Yiqi Qian
- Medical Practice Evaluation Center, Massachusetts General Hospital
| | - Bridget Bunda
- Medical Practice Evaluation Center, Massachusetts General Hospital
| | - Kevin L. Ard
- From the Division of Infectious Diseases
- Harvard Medical School
| | - Ingrid V. Bassett
- From the Division of Infectious Diseases
- Medical Practice Evaluation Center, Massachusetts General Hospital
- Harvard Medical School
- Harvard University Center for AIDS Research, Harvard University, Boston, MA
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Lo CH, Nguyen LH, Drew DA, Warner ET, Joshi AD, Graham MS, Anyane-Yeboa A, Shebl FM, Astley CM, Figueiredo JC, Guo CG, Ma W, Mehta RS, Kwon S, Song M, Davies R, Capdevila J, Sudre CH, Wolf J, Cozier YC, Rosenberg L, Wilkens LR, Haiman CA, Marchand LL, Palmer JR, Spector TD, Ourselin S, Steves CJ, Chan AT. Race, ethnicity, community-level socioeconomic factors, and risk of COVID-19 in the United States and the United Kingdom. EClinicalMedicine 2021; 38:101029. [PMID: 34308322 PMCID: PMC8285255 DOI: 10.1016/j.eclinm.2021.101029] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/29/2021] [Accepted: 06/29/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND There is limited prior investigation of the combined influence of personal and community-level socioeconomic factors on racial/ethnic disparities in individual risk of coronavirus disease 2019 (COVID-19). METHODS We performed a cross-sectional analysis nested within a prospective cohort of 2,102,364 participants from March 29, 2020 in the United States (US) and March 24, 2020 in the United Kingdom (UK) through December 02, 2020 via the COVID Symptom Study smartphone application. We examined the contribution of community-level deprivation using the Neighborhood Deprivation Index (NDI) and the Index of Multiple Deprivation (IMD) to observe racial/ethnic disparities in COVID-19 incidence. ClinicalTrials.gov registration: NCT04331509. FINDINGS Compared with non-Hispanic White participants, the risk for a positive COVID-19 test was increased in the US for non-Hispanic Black (multivariable-adjusted odds ratio [OR], 1.32; 95% confidence interval [CI], 1.18-1.47) and Hispanic participants (OR, 1.42; 95% CI, 1.33-1.52) and in the UK for Black (OR, 1.17; 95% CI, 1.02-1.34), South Asian (OR, 1.39; 95% CI, 1.30-1.49), and Middle Eastern participants (OR, 1.38; 95% CI, 1.18-1.61). This elevated risk was associated with living in more deprived communities according to the NDI/IMD. After accounting for downstream mediators of COVID-19 risk, community-level deprivation still mediated 16.6% and 7.7% of the excess risk in Black compared to White participants in the US and the UK, respectively. INTERPRETATION Our results illustrate the critical role of social determinants of health in the disproportionate COVID-19 risk experienced by racial and ethnic minorities.
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Affiliation(s)
- Chun-Han Lo
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Long H. Nguyen
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - David A. Drew
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Erica T. Warner
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA
- Harvard/MGH Center on Genomics, Vulnerable Populations, And Health Disparities, Massachusetts General Hospital, Boston, MA, USA
| | - Amit D. Joshi
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mark S. Graham
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Adjoa Anyane-Yeboa
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Fatma M. Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Christina M. Astley
- Computational Epidemiology Lab and Division of Endocrinology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Jane C. Figueiredo
- Department of Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles California, USA
| | - Chuan-Guo Guo
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Wenjie Ma
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Raaj S. Mehta
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sohee Kwon
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mingyang Song
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Carole H. Sudre
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | | | | | - Lynn Rosenberg
- Slone Epidemiology Center, Boston University, Boston, MA, USA
| | - Lynne R. Wilkens
- Epidemiology Program, University of Hawaii Cancer Center, Honolulu, HI, USA
| | - Christopher A. Haiman
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Norris Comprehensive Cancer Center, Los Angeles, CA, USA
- Center for Genetic Epidemiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Loïc Le Marchand
- Epidemiology Program, University of Hawaii Cancer Center, Honolulu, HI, USA
| | - Julie R. Palmer
- Slone Epidemiology Center, Boston University, Boston, MA, USA
| | - Tim D. Spector
- Department of Twin Research and Genetic Epidemiology, King's College London, London, UK
| | - Sebastien Ourselin
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Claire J. Steves
- Department of Twin Research and Genetic Epidemiology, King's College London, London, UK
- Department of Ageing and Health, Guy's and St Thomas's NHS Foundation Trust, London, UK
| | - Andrew T. Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Corresponding author at: Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA.
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Blumenthal KG, Oreskovic NM, Fu X, Shebl FM, Mancini CM, Maniates JM, Walensky RP. High-cost, high-need patients: the impact of reported penicillin allergy. Am J Manag Care 2021; 26:154-161. [PMID: 32270982 DOI: 10.37765/ajmc.2020.42832] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES More than 90% of patients who report a penicillin allergy have the allergy disproved when tested. Unnecessary use of alternative (non-beta-lactam) antibiotics can result in more treatment failures and adverse reactions. We described the prevalence and impact of a reported penicillin allergy in high-cost, high-need (HCHN) patients. STUDY DESIGN Retrospective cohort. METHODS We identified HCHN patients in a care management program of an urban academic medical center (January 1, 2014, to December 31, 2016). We used multivariable logistic regression models to determine the association between a reported penicillin allergy and antibiotic use. We used multivariable Poisson regression models to determine the association between a reported penicillin allergy, with or without multiple drug intolerance syndrome (MDIS; ≥3 reported drug allergies), and healthcare resource utilization (HRU). RESULTS Of 1870 HCHN patients, 383 (20%) reported penicillin allergy, 835 (45%) had MDIS, and 290 (16%) had both. HCHN patients reporting penicillin allergy had an increased odds of beta-lactam alternative antibiotic use (adjusted odds ratio, 3.84; 95% CI, 2.17-6.80). HRU was significantly higher for patients reporting a penicillin allergy alone (adjusted relative risk [aRR], 1.13; 95% CI, 1.03-1.25) and with concurrent MDIS (aRR, 1.20; 95% CI, 1.08-1.34). CONCLUSIONS HCHN patients had a high burden of reported drug allergy. A reported penicillin allergy conferred a 4-fold increased odds of beta-lactam alternative antibiotic use. Reporting penicillin allergy, with and without MDIS, was associated with significantly more HRU. HCHN care management programs should consider systematic drug allergy evaluations to optimize antibiotic use in these fragile patients.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, The Medical Practice Evaluation Center, The Mongan Institute, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114.
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25
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Baggett TP, Scott JA, Le MH, Shebl FM, Panella C, Losina E, Flanagan C, Gaeta JM, Neilan A, Hyle EP, Mohareb A, Reddy KP, Siedner MJ, Harling G, Weinstein MC, Ciaranello A, Kazemian P, Freedberg KA. Clinical Outcomes, Costs, and Cost-effectiveness of Strategies for Adults Experiencing Sheltered Homelessness During the COVID-19 Pandemic. JAMA Netw Open 2020; 3:e2028195. [PMID: 33351082 PMCID: PMC7756240 DOI: 10.1001/jamanetworkopen.2020.28195] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Approximately 356 000 people stay in homeless shelters nightly in the United States. They have high risk of contracting coronavirus disease 2019 (COVID-19). OBJECTIVE To assess the estimated clinical outcomes, costs, and cost-effectiveness associated with strategies for COVID-19 management among adults experiencing sheltered homelessness. DESIGN, SETTING, AND PARTICIPANTS This decision analytic model used a simulated cohort of 2258 adults residing in homeless shelters in Boston, Massachusetts. Cohort characteristics and costs were adapted from Boston Health Care for the Homeless Program. Disease progression, transmission, and outcomes data were taken from published literature and national databases. Surging, growing, and slowing epidemics (effective reproduction numbers [Re], 2.6, 1.3, and 0.9, respectively) were examined. Costs were from a health care sector perspective, and the time horizon was 4 months, from April to August 2020. EXPOSURES Daily symptom screening with polymerase chain reaction (PCR) testing of individuals with positive symptom screening results, universal PCR testing every 2 weeks, hospital-based COVID-19 care, alternative care sites (ACSs) for mild or moderate COVID-19, and temporary housing were each compared with no intervention. MAIN OUTCOMES AND MEASURES Cumulative infections and hospital-days, costs to the health care sector (US dollars), and cost-effectiveness, as incremental cost per case of COVID-19 prevented. RESULTS The simulated population of 2258 sheltered homeless adults had a mean (SD) age of 42.6 (9.04) years. Compared with no intervention, daily symptom screening with ACSs for pending tests or confirmed COVID-19 and mild or moderate disease was associated with 37% fewer infections (1954 vs 1239) and 46% lower costs ($6.10 million vs $3.27 million) at an Re of 2.6, 75% fewer infections (538 vs 137) and 72% lower costs ($1.46 million vs $0.41 million) at an Re of 1.3, and 51% fewer infections (174 vs 85) and 51% lower costs ($0.54 million vs $0.26 million) at an Re of 0.9. Adding PCR testing every 2 weeks was associated with a further decrease in infections; incremental cost per case prevented was $1000 at an Re of 2.6, $27 000 at an Re of 1.3, and $71 000 at an Re of 0.9. Temporary housing with PCR every 2 weeks was most effective but substantially more expensive than other options. Compared with no intervention, temporary housing with PCR every 2 weeks was associated with 81% fewer infections (376) and 542% higher costs ($39.12 million) at an Re of 2.6, 82% fewer infections (95) and 2568% higher costs ($38.97 million) at an Re of 1.3, and 59% fewer infections (71) and 7114% higher costs ($38.94 million) at an Re of 0.9. Results were sensitive to cost and sensitivity of PCR and ACS efficacy in preventing transmission. CONCLUSIONS AND RELEVANCE In this modeling study of simulated adults living in homeless shelters, daily symptom screening and ACSs were associated with fewer severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and decreased costs compared with no intervention. In a modeled surging epidemic, adding universal PCR testing every 2 weeks was associated with further decrease in SARS-CoV-2 infections at modest incremental cost and should be considered during future surges.
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Affiliation(s)
- Travis P. Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts
| | - Justine A. Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
| | - Mylinh H. Le
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
| | - Fatma M. Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
| | | | - Elena Losina
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
- Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Policy and Innovation eValuation in Orthopedic Treatments Center, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Clare Flanagan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
| | - Jessie M. Gaeta
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Anne Neilan
- Harvard Medical School, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Massachusetts General Hospital, Boston
- Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital, Boston
| | - Emily P. Hyle
- Harvard Medical School, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Massachusetts General Hospital, Boston
- Harvard University Center for AIDS Research, Boston, Massachusetts
| | - Amir Mohareb
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Massachusetts General Hospital, Boston
| | - Krishna P. Reddy
- Harvard Medical School, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston
| | - Mark J. Siedner
- Harvard Medical School, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Massachusetts General Hospital, Boston
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Guy Harling
- Department of Epidemiology and Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, United Kingdom
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of Witwatersrand, Johannesburg, South Africa
| | - Milton C. Weinstein
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Andrea Ciaranello
- Harvard Medical School, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Massachusetts General Hospital, Boston
- Harvard University Center for AIDS Research, Boston, Massachusetts
| | - Pooyan Kazemian
- Department of Operations, Weatherhead School of Management, Case Western Reserve University, Cleveland, Ohio
| | - Kenneth A. Freedberg
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Massachusetts General Hospital, Boston
- Harvard University Center for AIDS Research, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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26
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Reddy KP, Denkinger CM, Broger T, McCann NC, Gupta-Wright A, Kerkhoff AD, Pei PP, Shebl FM, Fielding KL, Nicol MP, Horsburgh CR, Meintjes G, Freedberg KA, Wood R, Walensky RP. Cost-effectiveness of a novel lipoarabinomannan test for tuberculosis in patients with HIV. Clin Infect Dis 2020; 73:e2077-e2085. [PMID: 33200169 PMCID: PMC8492225 DOI: 10.1093/cid/ciaa1698] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 11/13/2020] [Indexed: 02/03/2023] Open
Abstract
Background A novel urine lipoarabinomannan assay (FujiLAM) has higher sensitivity and higher cost than the first-generation AlereLAM assay. We evaluated the cost-effectiveness of FujiLAM for tuberculosis testing among hospitalized people with human immunodeficiency virus (HIV), irrespective of symptoms. Methods We used a microsimulation model to project clinical and economic outcomes of 3 testing strategies: (1) sputum Xpert MTB/RIF (Xpert), (2) sputum Xpert plus urine AlereLAM (Xpert+AlereLAM), (3) sputum Xpert plus urine FujiLAM (Xpert+FujiLAM). The modeled cohort matched that of a 2-country clinical trial. We applied diagnostic yields from a retrospective study (yields for Xpert/Xpert+AlereLAM/Xpert+FujiLAM among those with CD4 <200 cells/µL: 33%/62%/70%; among those with CD4 ≥200 cells/µL: 33%/35%/47%). Costs of Xpert/AlereLAM/FujiLAM were US$15/3/6 (South Africa) and $25/3/6 (Malawi). Xpert+FujiLAM was considered cost-effective if its incremental cost-effectiveness ratio (US$/year-of-life saved) was <$940 (South Africa) and <$750 (Malawi). We varied key parameters in sensitivity analysis and performed a budget impact analysis of implementing FujiLAM countrywide. Results Compared with Xpert+AlereLAM, Xpert+FujiLAM increased life expectancy by 0.2 years for those tested in South Africa and Malawi. Xpert+FujiLAM was cost-effective in both countries. Xpert+FujiLAM for all patients remained cost-effective compared with sequential testing and CD4-stratified testing strategies. FujiLAM use added 3.5% (South Africa) and 4.7% (Malawi) to 5-year healthcare costs of tested patients, primarily reflecting ongoing HIV treatment costs among survivors. Conclusions FujiLAM with Xpert for tuberculosis testing in hospitalized people with HIV is likely to increase life expectancy and be cost-effective at the currently anticipated price in South Africa and Malawi. Additional studies should evaluate FujiLAM in clinical practice settings.
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Affiliation(s)
- Krishna P Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | | | - Nicole C McCann
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Ankur Gupta-Wright
- Division of Infection and Immunity, University College London, London, United Kingdom.,Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Malawi-Liverpool-Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases, and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - Pamela P Pei
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark P Nicol
- Infection and Immunity, University of Western Australia, Perth, Australia
| | - C Robert Horsburgh
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Graeme Meintjes
- Department of Medicine, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular Medicine, Cape Town, South Africa
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Robin Wood
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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27
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Reddy KP, Shebl FM, Foote JHA, Harling G, Scott JA, Panella C, Fitzmaurice KP, Flanagan C, Hyle EP, Neilan AM, Mohareb AM, Bekker LG, Lessells RJ, Ciaranello AL, Wood R, Losina E, Freedberg KA, Kazemian P, Siedner MJ. Cost-effectiveness of public health strategies for COVID-19 epidemic control in South Africa: a microsimulation modelling study. Lancet Glob Health 2020; 9:e120-e129. [PMID: 33188729 PMCID: PMC7834260 DOI: 10.1016/s2214-109x(20)30452-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/25/2020] [Accepted: 10/06/2020] [Indexed: 12/24/2022]
Abstract
Background Health-care resource constraints in low-income and middle-income countries necessitate the identification of cost-effective public health interventions to address COVID-19. We aimed to develop a dynamic COVID-19 microsimulation model to assess clinical and economic outcomes and cost-effectiveness of epidemic control strategies in KwaZulu-Natal province, South Africa. Methods We compared different combinations of five public health interventions: health-care testing alone, where diagnostic testing is done only for individuals presenting to health-care centres; contact tracing in households of cases; isolation centres, for cases not requiring hospital admission; mass symptom screening and molecular testing for symptomatic individuals by community health-care workers; and quarantine centres, for household contacts who test negative. We calibrated infection transmission rates to match effective reproduction number (Re) estimates reported in South Africa. We assessed two main epidemic scenarios for a period of 360 days, with an Re of 1·5 and 1·2. Strategies with incremental cost-effectiveness ratio (ICER) of less than US$3250 per year of life saved were considered cost-effective. We also did sensitivity analyses by varying key parameters (Re values, molecular testing sensitivity, and efficacies and costs of interventions) to determine the effect on clinical and cost projections. Findings When Re was 1·5, health-care testing alone resulted in the highest number of COVID-19 deaths during the 360-day period. Compared with health-care testing alone, a combination of health-care testing, contact tracing, use of isolation centres, mass symptom screening, and use of quarantine centres reduced mortality by 94%, increased health-care costs by 33%, and was cost-effective (ICER $340 per year of life saved). In settings where quarantine centres were not feasible, a combination of health-care testing, contact tracing, use of isolation centres, and mass symptom screening was cost-effective compared with health-care testing alone (ICER $590 per year of life saved). When Re was 1·2, health-care testing, contact tracing, use of isolation centres, and use of quarantine centres was the least costly strategy, and no other strategies were cost-effective. In sensitivity analyses, a combination of health-care testing, contact tracing, use of isolation centres, mass symptom screening, and use of quarantine centres was generally cost-effective, with the exception of scenarios in which Re was 2·6 and when efficacies of isolation centres and quarantine centres for transmission reduction were reduced. Interpretation In South Africa, strategies involving household contact tracing, isolation, mass symptom screening, and quarantining household contacts who test negative would substantially reduce COVID-19 mortality and would be cost-effective. The optimal combination of interventions depends on epidemic growth characteristics and practical implementation considerations. Funding US National Institutes of Health, Royal Society, Wellcome Trust.
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Affiliation(s)
- Krishna P Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Julia H A Foote
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Guy Harling
- Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Harvard Center for Population and Development Studies, Harvard T H Chan School of Public Health, Boston, MA, USA; Africa Health Research Institute, Durban, South Africa; Institute for Global Health, University College London, London, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of Witwatersrand, Johannesburg, South Africa
| | - Justine A Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Panella
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Kieran P Fitzmaurice
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Clare Flanagan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Emily P Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Harvard University Center for AIDS Research, Cambridge, MA, USA
| | - Anne M Neilan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Amir M Mohareb
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Linda-Gail Bekker
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Richard J Lessells
- KwaZulu-Natal Research Innovation and Sequencing, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Andrea L Ciaranello
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Harvard University Center for AIDS Research, Cambridge, MA, USA
| | - Robin Wood
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Elena Losina
- Harvard Medical School, Boston, MA, USA; Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA; Orthopaedic and Arthritis Center for Outcomes Research and Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Pooyan Kazemian
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Mark J Siedner
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Africa Health Research Institute, Durban, South Africa
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Ochoa Chaar CI, Kim TI, Shebl FM, Dardik A. The Use of Embolic Protection Devices during Lower Extremity Peripheral Vascular Interventions. Ann Vasc Surg 2020; 69:9-16. [DOI: 10.1016/j.avsg.2020.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/28/2020] [Accepted: 06/01/2020] [Indexed: 11/28/2022]
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Baggett TP, Scott JA, Le MH, Shebl FM, Panella C, Losina E, Flanagan C, Gaeta JM, Neilan A, Hyle EP, Mohareb A, Reddy KP, Siedner MJ, Harling G, Weinstein MC, Ciaranello A, Kazemian P, Freedberg KA. Clinical Outcomes, Costs, and Cost-effectiveness of Strategies for People Experiencing Sheltered Homelessness During the COVID-19 Pandemic. medRxiv 2020. [PMID: 32817967 PMCID: PMC7430611 DOI: 10.1101/2020.08.07.20170498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Importance: Approximately 356,000 people stay in homeless shelters nightly in the US. They are at high risk for COVID-19. Objective: To assess clinical outcomes, costs, and cost-effectiveness of strategies for COVID-19 management among sheltered homeless adults. Design: We developed a dynamic microsimulation model of COVID-19 in sheltered homeless adults in Boston, Massachusetts. We used cohort characteristics and costs from Boston Health Care for the Homeless Program. Disease progression, transmission, and outcomes data were from published literature and national databases. We examined surging, growing, and slowing epidemics (effective reproduction numbers [Re] 2.6, 1.3, and 0.9). Costs were from a health care sector perspective; time horizon was 4 months, from April to August 2020. Setting & Participants: Simulated cohort of 2,258 adults residing in homeless shelters in Boston. Interventions: We assessed daily symptom screening with polymerase chain reaction (PCR) testing of screen-positives, universal PCR testing every 2 weeks, hospital-based COVID-19 care, alternate care sites [ACSs] for mild/moderate COVID-19, and temporary housing, each compared to no intervention. Main Outcomes and Measures: Cumulative infections and hospital-days, costs to the health care sector (US dollars), and cost-effectiveness, as incremental cost per case prevented of COVID-19. Results: We simulated a population of 2,258 sheltered homeless adults with mean age of 42.6 years. Compared to no intervention, daily symptom screening with ACSs for pending tests or confirmed COVID-19 and mild/moderate disease led to 37% fewer infections and 46% lower costs (Re=2.6), 75% fewer infections and 72% lower costs (Re=1.3), and 51% fewer infections and 51% lower costs (Re=0.9). Adding PCR testing every 2 weeks further decreased infections; incremental cost per case prevented was $1,000 (Re=2.6), $27,000 (Re=1.3), and $71,000 (Re=0.9). Temporary housing with PCR every 2 weeks was most effective but substantially more costly than other options. Results were sensitive to cost and sensitivity of PCR and ACS efficacy in preventing transmission. Conclusions & Relevance: In this modeling study of simulated adults living in homeless shelters, daily symptom screening and ACSs were associated with fewer COVID-19 infections and decreased costs compared with no intervention. In a modeled surging epidemic, adding universal PCR testing every 2 weeks was associated with further decrease in COVID-19 infections at modest incremental cost and should be considered during future surges.
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Affiliation(s)
- Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA.,Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA
| | - Justine A Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Mylinh H Le
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Christopher Panella
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Elena Losina
- Department of Biostatistics, Boston University School of Public Health, Boston, MA.,Orthopedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA.,Policy and Innovation eValuation in Orthopedic Treatments (PIVOT) Center, Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Clare Flanagan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Jessie M Gaeta
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA.,Section of General Internal Medicine, Boston University School of Medicine
| | - Anne Neilan
- Harvard Medical School, Boston, MA.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital, Boston, MA
| | - Emily P Hyle
- Harvard Medical School, Boston, MA.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Harvard University Center for AIDS Research, Boston, MA
| | - Amir Mohareb
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
| | - Krishna P Reddy
- Harvard Medical School, Boston, MA.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Mark J Siedner
- Harvard Medical School, Boston, MA.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Guy Harling
- Department of Epidemiology and Harvard Center for Population & Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Africa Health Research Institute, KwaZulu-Natal, South Africa.,Institute for Global Health, University College London, London, UK.,MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of Witwatersrand, South Africa
| | - Milton C Weinstein
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Andrea Ciaranello
- Harvard Medical School, Boston, MA.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Harvard University Center for AIDS Research, Boston, MA
| | - Pooyan Kazemian
- Department of Operations, Weatherhead School of Management, Case Western Reserve University, Cleveland, OH
| | - Kenneth A Freedberg
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA.,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.,Harvard University Center for AIDS Research, Boston, MA.,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA
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Reddy KP, Shebl FM, Foote JHA, Harling G, Scott JA, Panella C, Fitzmaurice KP, Flanagan C, Hyle EP, Neilan AM, Mohareb AM, Bekker LG, Lessells RJ, Ciaranello AL, Wood R, Losina E, Freedberg KA, Kazemian P, Siedner MJ. Cost-effectiveness of public health strategies for COVID-19 epidemic control in South Africa: a microsimulation modelling study. medRxiv 2020. [PMID: 32637979 PMCID: PMC7340205 DOI: 10.1101/2020.06.29.20140111] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Healthcare resource constraints in low and middle-income countries necessitate selection of cost-effective public health interventions to address COVID-19. Methods We developed a dynamic COVID-19 microsimulation model to evaluate clinical and economic outcomes and cost-effectiveness of epidemic control strategies in KwaZulu-Natal, South Africa. Interventions assessed were Healthcare Testing (HT), where diagnostic testing is performed only for those presenting to healthcare centres; Contact Tracing (CT) in households of cases; Isolation Centres (IC), for cases not requiring hospitalisation; community health worker-led Mass Symptom Screening and molecular testing for symptomatic individuals (MS); and Quarantine Centres (QC), for household contacts who test negative. Given uncertainties about epidemic dynamics in South Africa, we evaluated two main epidemic scenarios over 360 days, with effective reproduction numbers (Re) of 1·5 and 1·2. We compared HT, HT+CT, HT+CT+IC, HT+CT+IC+MS, HT+CT+IC+QC, and HT+CT+IC+MS+QC, considering strategies with incremental cost-effectiveness ratio (ICER) <US$3,250/year-of-life saved (YLS) cost-effective. In sensitivity analyses, we varied Re, molecular testing sensitivity, and efficacies and costs of interventions. Findings With Re 1·5, HT resulted in the most COVID-19 deaths over 360 days. Compared with HT, HT+CT+IC+MS+QC reduced mortality by 94%, increased costs by 33%, and was cost-effective (ICER $340/YLS). In settings where quarantine centres cannot be implemented, HT+CT+IC+MS was cost-effective compared with HT (ICER $590/YLS). With Re 1·2, HT+CT+IC+QC was the least costly strategy, and no other strategy was cost-effective. HT+CT+IC+MS+QC was cost-effective in many sensitivity analyses; notable exceptions were when Re was 2·6 and when efficacies of ICs and QCs for transmission reduction were reduced. Interpretation In South Africa, strategies involving household contact tracing, isolation, mass symptom screening, and quarantining household contacts who test negative would substantially reduce COVID-19 mortality and be cost-effective. The optimal combination of interventions depends on epidemic growth characteristics and practical implementation considerations.
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Affiliation(s)
- Krishna P Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Julia H A Foote
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Guy Harling
- Department of Epidemiology and Harvard Center for Population & Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Africa Health Research Institute, KwaZulu-Natal, South Africa.,Institute for Global Health, University College London, London, UK.,MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of Witwatersrand, South Africa
| | - Justine A Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Panella
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Kieran P Fitzmaurice
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Clare Flanagan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Emily P Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research, Cambridge, MA, USA
| | - Anne M Neilan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Amir M Mohareb
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Linda-Gail Bekker
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Richard J Lessells
- KwaZulu-Natal Research Innovation and Sequencing (KRISP), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Andrea L Ciaranello
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research, Cambridge, MA, USA
| | - Robin Wood
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Elena Losina
- Harvard Medical School, Boston, MA, USA.,Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA.,Orthopedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Policy and Innovation eValuation in Orthopedic Treatments (PIVOT) Center, Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Pooyan Kazemian
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Mark J Siedner
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Africa Health Research Institute, KwaZulu-Natal, South Africa.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
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Luckett DJ, Laber EB, El-Kamary SS, Fan C, Jhaveri R, Perou CM, Shebl FM, Kosorok MR. Receiver operating characteristic curves and confidence bands for support vector machines. Biometrics 2020; 77:1422-1430. [PMID: 32865820 DOI: 10.1111/biom.13365] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 07/17/2020] [Accepted: 08/17/2020] [Indexed: 11/27/2022]
Abstract
Many problems that appear in biomedical decision-making, such as diagnosing disease and predicting response to treatment, can be expressed as binary classification problems. The support vector machine (SVM) is a popular classification technique that is robust to model misspecification and effectively handles high-dimensional data. The relative costs of false positives and false negatives can vary across application domains. The receiving operating characteristic (ROC) curve provides a visual representation of the trade-off between these two types of errors. Because the SVM does not produce a predicted probability, an ROC curve cannot be constructed in the traditional way of thresholding a predicted probability. However, a sequence of weighted SVMs can be used to construct an ROC curve. Although ROC curves constructed using weighted SVMs have great potential for allowing ROC curves analyses that cannot be done by thresholding predicted probabilities, their theoretical properties have heretofore been underdeveloped. We propose a method for constructing confidence bands for the SVM ROC curve and provide the theoretical justification for the SVM ROC curve by showing that the risk function of the estimated decision rule is uniformly consistent across the weight parameter. We demonstrate the proposed confidence band method using simulation studies. We present a predictive model for treatment response in breast cancer as an illustrative example.
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Affiliation(s)
- Daniel J Luckett
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
| | - Eric B Laber
- Department of Statistics, North Carolina State University, Raleigh, North Carolina
| | - Samer S El-Kamary
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland
| | - Cheng Fan
- Department of Genetics, University of North Carolina, Chapel Hill, North Carolina
| | - Ravi Jhaveri
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Charles M Perou
- Department of Genetics, University of North Carolina, Chapel Hill, North Carolina
| | - Fatma M Shebl
- Department of Epidemiology, Yale University, New Haven, Connecticut
| | - Michael R Kosorok
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
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Neilan AM, Losina E, Bangs AC, Flanagan C, Panella C, Eskibozkurt GE, Mohareb A, Hyle EP, Scott JA, Weinstein MC, Siedner MJ, Reddy KP, Harling G, Freedberg KA, Shebl FM, Kazemian P, Ciaranello AL. Clinical Impact, Costs, and Cost-Effectiveness of Expanded SARS-CoV-2 Testing in Massachusetts. medRxiv 2020:2020.07.23.20160820. [PMID: 32743604 PMCID: PMC7386528 DOI: 10.1101/2020.07.23.20160820] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background We projected the clinical and economic impact of alternative testing strategies on COVID-19 incidence and mortality in Massachusetts using a microsimulation model. Methods We compared five testing strategies: 1) PCR-severe-only: PCR testing only patients with severe/critical symptoms; 2) Self-screen: PCR-severe-only plus self-assessment of COVID-19-consistent symptoms with self-isolation if positive; 3) PCR-any-symptom: PCR for any COVID-19-consistent symptoms with self-isolation if positive; 4) PCR-all: PCR-any-symptom and one-time PCR for the entire population; and, 5) PCR-all-repeat: PCR-all with monthly re-testing. We examined effective reproduction numbers (R e , 0.9-2.0) at which policy conclusions would change. We used published data on disease progression and mortality, transmission, PCR sensitivity/specificity (70/100%) and costs. Model-projected outcomes included infections, deaths, tests performed, hospital-days, and costs over 180-days, as well as incremental cost-effectiveness ratios (ICERs, $/quality-adjusted life-year [QALY]). Results In all scenarios, PCR-all-repeat would lead to the best clinical outcomes and PCR-severe-only would lead to the worst; at R e 0.9, PCR-all-repeat vs. PCR-severe-only resulted in a 63% reduction in infections and a 44% reduction in deaths, but required >65-fold more tests/day with 4-fold higher costs. PCR-all-repeat had an ICER <$100,000/QALY only when R e ≥1.8. At all R e values, PCR-any-symptom was cost-saving compared to other strategies. Conclusions Testing people with any COVID-19-consistent symptoms would be cost-saving compared to restricting testing to only those with symptoms severe enough to warrant hospital care. Expanding PCR testing to asymptomatic people would decrease infections, deaths, and hospitalizations. Universal screening would be cost-effective when paired with monthly retesting in settings where the COVID-19 pandemic is surging.
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Affiliation(s)
- Anne M Neilan
- Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Elena Losina
- Harvard Medical School, Boston, MA
- Orthopedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
- Policy and Innovation evaluation in Orthopedic Treatments (PIVOT) Center, Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Audrey C Bangs
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Clare Flanagan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Christopher Panella
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - G Ege Eskibozkurt
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Amir Mohareb
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Emily P Hyle
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Harvard University Center for AIDS Research, Cambridge, MA
| | - Justine A Scott
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Milton C Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mark J Siedner
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Krishna P Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Guy Harling
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Institute for Global Health, University College London, London, UK
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
| | - Kenneth A Freedberg
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Pooyan Kazemian
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Andrea L Ciaranello
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Harvard University Center for AIDS Research, Cambridge, MA
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Reddy KP, Bulteel AJB, Levy DE, Torola P, Hyle EP, Hou T, Osher B, Yu L, Shebl FM, Paltiel AD, Freedberg KA, Weinstein MC, Rigotti NA, Walensky RP. Novel microsimulation model of tobacco use behaviours and outcomes: calibration and validation in a US population. BMJ Open 2020; 10:e032579. [PMID: 32404384 PMCID: PMC7228509 DOI: 10.1136/bmjopen-2019-032579] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Simulation models can project effects of tobacco use and cessation and inform tobacco control policies. Most existing tobacco models do not explicitly include relapse, a key component of the natural history of tobacco use. Our objective was to develop, calibrate and validate a novel individual-level microsimulation model that would explicitly include smoking relapse and project cigarette smoking behaviours and associated mortality risks. METHODS We developed the Simulation of Tobacco and Nicotine Outcomes and Policy (STOP) model, in which individuals transition monthly between tobacco use states (current/former/never) depending on rates of initiation, cessation and relapse. Simulated individuals face tobacco use-stratified mortality risks. For US women and men, we conducted cross-validation with a Cancer Intervention and Surveillance Modeling Network (CISNET) model. We then incorporated smoking relapse and calibrated cessation rates to reflect the difference between a transient quit attempt and sustained abstinence. We performed external validation with the National Health Interview Survey (NHIS) and the linked National Death Index. Comparisons were based on root-mean-square error (RMSE). RESULTS In cross-validation, STOP-generated projections of current/former/never smoking prevalence fit CISNET-projected data well (coefficient of variation (CV)-RMSE≤15%). After incorporating smoking relapse, multiplying the CISNET-reported cessation rates for women/men by 7.75/7.25, to reflect the ratio of quit attempts to sustained abstinence, resulted in the best approximation to CISNET-reported smoking prevalence (CV-RMSE 2%/3%). In external validation using these new multipliers, STOP-generated cumulative mortality curves for 20-year-old current smokers and never smokers each had CV-RMSE ≤1% compared with NHIS. In simulating those surveyed by NHIS in 1997, the STOP-projected prevalence of current/former/never smokers annually (1998-2009) was similar to that reported by NHIS (CV-RMSE 12%). CONCLUSIONS The STOP model, with relapse included, performed well when validated to US smoking prevalence and mortality. STOP provides a flexible framework for policy-relevant analysis of tobacco and nicotine product use.
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Affiliation(s)
- Krishna P Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander J B Bulteel
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Douglas E Levy
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pamela Torola
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emily P Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Taige Hou
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Benjamin Osher
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Liyang Yu
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Milton C Weinstein
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Mustafa I, Firdous N, Shebl FM, Shi Z, Saeed M, Zahir Z, Zayed H. Genetic epidemiology of beta-thalassemia in the Maldives: 23 years of a beta-thalassemia screening program. Gene 2020; 741:144544. [DOI: 10.1016/j.gene.2020.144544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/13/2020] [Accepted: 03/08/2020] [Indexed: 11/30/2022]
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Millham LRI, Scott JA, Sax PE, Shebl FM, Reddy KP, Losina E, Walensky RP, Freedberg KA. Clinical and Economic Impact of Ibalizumab for People With Multidrug-Resistant HIV in the United States. J Acquir Immune Defic Syndr 2020; 83:148-156. [PMID: 31929403 PMCID: PMC7066538 DOI: 10.1097/qai.0000000000002241] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND We projected the clinical outcomes, cost-effectiveness, and budget impact of ibalizumab plus an optimized background regimen (OBR) for people with multidrug-resistant (MDR) HIV in the United States. METHODS Using the Cost-Effectiveness of Preventing AIDS Complications microsimulation model and a health care sector perspective, we compared 2 treatment strategies for MDR HIV: (1) IBA + OBR-ibalizumab plus OBR and (2) OBR-OBR alone. Ibalizumab efficacy and cohort characteristics were from trial data: mean age 49 years, 85% male, and mean CD4 150/µL. Six-month viral suppression was 50% with IBA + OBR and 0% with OBR. The ibalizumab loading dose cost $10,500, and subsequent ibalizumab injections cost $8400/month; OBR cost $4500/month. Incremental cost-effectiveness ratios (ICERs) were calculated using discounted (3%/year) quality-adjusted life years (QALYs) and costs. ICERs ≤$100,000/QALY were considered cost-effective. We performed sensitivity analysis on key parameters and examined budget impact. RESULTS In the base case, 5-year survival increased from 38% with OBR to 47% with IBA + OBR. Lifetime costs were $301,700/person with OBR and $661,800/person with IBA + OBR; the ICER for IBA + OBR compared with OBR was $260,900/QALY. IBA + OBR was not cost-effective even with 100% efficacy. IBA + OBR became cost-effective at base case efficacy if ibalizumab cost was reduced by ≥88%. For an estimated 12,000 people with MDR HIV in the United States, IBA + OBR increased care costs by $1.8 billion (1.5% of total treatment budget) over 5 years. CONCLUSIONS For people with MDR HIV lacking other treatment options, ibalizumab will substantially increase survival when effective. Although adding ibalizumab to OBR is not cost-effective, the low number of eligible patients in the United States makes the budget impact relatively small.
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Affiliation(s)
- Lucia R I Millham
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Justine A Scott
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Paul E Sax
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA
| | - Fatma M Shebl
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
| | - Krishna P Reddy
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Elena Losina
- Harvard Medical School, Boston, MA
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Rochelle P Walensky
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
- Harvard University Center for AIDS Research, Cambridge, MA; and
| | - Kenneth A Freedberg
- Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
- Harvard University Center for AIDS Research, Cambridge, MA; and
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
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Abstract
IMPORTANCE Treatment advances in diabetes can meaningfully improve outcomes only if they effectively reach the populations at risk. OBJECTIVES To evaluate whether the cascade of US diabetes care, defined as diabetes diagnosis, linkage to care, and achievement of individual and combined treatment targets, improved from 2005 to 2016 and to investigate potential disparities in US diabetes care. DESIGN, SETTING, AND PARTICIPANTS Nationally representative, serial cross-sectional studies included in the 2005-2016 National Health and Nutrition Examination Survey were evaluated. Data on nonpregnant US adults (age ≥18 years) with diabetes who had reported fasting for 9 or more hours (n = 1742 diagnosed and 746 undiagnosed) were included. Data analysis was performed from August 1, 2018, to May 10, 2019. EXPOSURES Time period (2005-2008, 2009-2012, and 2013-2016), age, sex, race/ethnicity, health insurance, and educational level incorporated into logistic regression models predicting odds of target achievement. MAIN OUTCOMES AND MEASURES Proportion of participants overall and stratified by age, sex, and race/ethnicity who were linked to diabetes care and met glycemic (hemoglobin A1c <7.0%-8.5%, depending on age and complications), blood pressure (<140/90 mm Hg), cholesterol level (low-density lipoprotein cholesterol <100 mg/dL), and smoking abstinence targets and a composite of all targets. RESULTS In 2013-2016, of 1742 US adults with diagnosed diabetes, 94% (95% CI, 92%-96%) were linked to diabetes care; 64% (95% CI, 58%-69%) met hemoglobin A1c level, 70% (95% CI, 64%-75%) met blood pressure level, and 57% (95% CI, 51%-62%) met cholesterol level targets; 85% were nonsmokers (95% CI, 82%-88%); and 23% (95% CI, 17%-29%) achieved the composite goal. Results were similar in 2005-2008 (composite 23%) and in 2009-2012 (composite 25%). There was no significant improvement in diagnosis or target achievement during the study period. Compared with middle-aged adults (45-64 years) with diagnosed diabetes, older patients (≥65 years) had higher odds (adjusted odds ratio [aOR], 1.70; 95% CI, 1.17-2.48) and younger adults (18-44 years) had lower odds (aOR, 0.53; 95% CI, 0.29-0.97) of meeting the composite target. Women had lower odds of achieving the composite target than men (aOR, 0.60; 95% CI, 0.45-0.80). Non-Hispanic black individuals vs non-Hispanic white individuals had lower odds of achieving the composite target (aOR, 0.57; 95% CI, 0.39-0.83). Having health insurance was the strongest predictor of linkage to diabetes care (aOR, 3.96; 95% CI, 2.34-6.69). CONCLUSIONS AND RELEVANCE It appears that the diabetes care cascade in the United States has not significantly improved between 2005 and 2016. This study's findings suggest that gaps in diabetes care that were present in 2005, particularly among younger adults (18-44 years), women, and nonwhite individuals, persist.
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Affiliation(s)
- Pooyan Kazemian
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston.,Division of General Internal Medicine, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston.,Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Nicole McCann
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston.,Division of General Internal Medicine, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts.,Division of Infectious Diseases, Massachusetts General Hospital, Boston
| | - Deborah J Wexler
- Harvard Medical School, Boston, Massachusetts.,Diabetes Unit, Massachusetts General Hospital, Boston
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Mehra R, Shebl FM, Cunningham SD, Magriples U, Barrette E, Herrera C, Kozhimannil KB, Ickovics JR. Area-level deprivation and preterm birth: results from a national, commercially-insured population. BMC Public Health 2019; 19:236. [PMID: 30813938 PMCID: PMC6391769 DOI: 10.1186/s12889-019-6533-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 02/12/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Area-level deprivation is associated with multiple adverse birth outcomes. Few studies have examined the mediating pathways through which area-level deprivation affects these outcomes. The objective of this study was to investigate the association between area-level deprivation and preterm birth, and examine the mediating effects of maternal medical, behavioural, and psychosocial factors. METHODS We conducted a retrospective cohort study using national, commercial health insurance claims data from 2011, obtained from the Health Care Cost Institute. Area-level deprivation was derived from principal components methods using ZIP code-level data. Multilevel structural equation modeling was used to examine mediating effects. RESULTS In total, 138,487 women with a live singleton birth residing in 14,577 ZIP codes throughout the United States were included. Overall, 5.7% of women had a preterm birth. In fully adjusted generalized estimation equation models, compared to women in the lowest quartile of area-level deprivation, odds of preterm birth increased by 9.6% among women in the second highest quartile (odds ratio (OR) 1.096; 95% confidence interval (CI) 1.021, 1.176), by 11.3% in the third highest quartile (OR 1.113; 95% CI 1.035, 1.195), and by 24.9% in the highest quartile (OR 1.249; 95% CI 1.165, 1.339). Hypertension and infection moderately mediated this association. CONCLUSIONS Even among commercially-insured women, area-level deprivation was associated with increased risk of preterm birth. Similar to individual socioeconomic status, area-level deprivation does not have a threshold effect. Implementation of policies to reduce area-level deprivation, and the screening and treatment of maternal mediators may be associated with a lower risk of preterm birth.
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Affiliation(s)
- Renee Mehra
- Yale School of Public Health, PO Box 208034, New Haven, CT, 06520-8034, USA.
| | - Fatma M Shebl
- Yale School of Public Health, PO Box 208034, New Haven, CT, 06520-8034, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, 100 Cambridge Street, Boston, MA, 02114, USA
| | | | - Urania Magriples
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, PO Box 208063, New Haven, CT, 06520, USA
| | - Eric Barrette
- Health Care Cost Institute, 1100 G Street NW, Suite 600, Washington, DC, 20005, USA
- Medtronic, 950 F Street NW, Suite 500, Washington, DC, 20004, USA
| | - Carolina Herrera
- Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA
| | - Katy B Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Jeannette R Ickovics
- Yale School of Public Health, PO Box 208034, New Haven, CT, 06520-8034, USA
- Yale-NUS College, 20 College Avenue West #03-401, Singapore, 138529, Singapore
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Ickovics JR, Duffany KO, Shebl FM, Peters SM, Read MA, Gilstad-Hayden KR, Schwartz MB. Implementing School-Based Policies to Prevent Obesity: Cluster Randomized Trial. Am J Prev Med 2019; 56:e1-e11. [PMID: 30573151 PMCID: PMC7050629 DOI: 10.1016/j.amepre.2018.08.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Healthier school environments can benefit students, and school wellness policies may result in meaningful enhancements. Schools participating in federal child nutrition programs must implement wellness policies as mandated by law. The primary study objective is to assess effectiveness of implementing school-based nutrition and physical activity policies on student BMI trajectories. STUDY DESIGN Cluster randomized trial using 2 × 2 factorial design. SETTING/PARTICIPANTS Twelve randomly selected schools in an urban district. Students were followed for 3 years through middle school, fifth to eighth grades (2011-2015, n=595 students, 92.3% participation, 85.2% retention). INTERVENTION Specific to randomized condition, support was provided for implementation of nutrition policies (e.g., alternatives to food-based rewards/celebrations) and physical activity policies (e.g., opportunities for physical activity during/after school). MAIN OUTCOME MEASURES Sex-/age-adjusted BMI percentile and BMI z-score; behavioral indicators. Data collected via standardized protocols. RESULTS Analyses followed intention-to-treat principles, with planned secondary analyses (conducted 2016-2018). Students at schools randomized to receive support for nutrition policy implementation had healthier BMI trajectories over time (F=3.20, p=0.02), with a greater magnitude over time and cumulatively significant effects 3 years post-intervention (β=-2.40, p=0.04). Overall, students at schools randomized to receive the nutrition intervention had an increase in BMI percentile of <1%, compared with students in other conditions, whereas BMI percentile increased 3%-4%. There was no difference in student BMI between those in schools with and without physical activity policy implementation. Examining behavioral correlates in eighth grade, students at schools randomized to the nutrition condition consumed fewer unhealthy foods and sugar-sweetened beverages, and ate less frequently at fast-food restaurants (all p<0.03). CONCLUSIONS This cluster randomized trial demonstrated effectiveness of providing support for implementation of school-based nutrition policies, but not physical activity policies, to limit BMI increases among middle school students. Results can guide future school interventions. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT02043626.
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Affiliation(s)
- Jeannette R Ickovics
- Yale School of Public Health, New Haven, Connecticut; Yale-NUS College, Singapore.
| | | | - Fatma M Shebl
- Yale School of Public Health, New Haven, Connecticut
| | - Sue M Peters
- New Haven Public Schools, New Haven, Connecticut
| | - Margaret A Read
- Rudd Center for Food Policy and Obesity, University of Connecticut, Hartford, Connecticut
| | | | - Marlene B Schwartz
- Rudd Center for Food Policy and Obesity, University of Connecticut, Hartford, Connecticut
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Cunningham SD, Lewis JB, Shebl FM, Boyd LM, Robinson MA, Grilo SA, Lewis SM, Pruett AL, Ickovics JR. Group Prenatal Care Reduces Risk of Preterm Birth and Low Birth Weight: A Matched Cohort Study. J Womens Health (Larchmt) 2019; 28:17-22. [DOI: 10.1089/jwh.2017.6817] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
| | | | | | - Lisa M. Boyd
- Yale School of Public Health, New Haven, Connecticut
| | | | | | - Susan M. Lewis
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anne L. Pruett
- Vanderbilt University Medical Center, Nashville, Tennessee
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Zayed H, Abdel Motal UM, Gopalakrishnan A, Ponnuraja C, Doss CGP, Rizk N, Shebl FM. Retinopathy of Type 1 Diabetes in Arab Countries: Systematic Review and Meta-Analysis. Ophthalmic Res 2018; 61:125-136. [PMID: 30045028 DOI: 10.1159/000489931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 05/09/2018] [Indexed: 11/19/2022]
Abstract
AIMS To conduct a systematic review and meta-analysis of retinopathy prevalence in patients with type 1 diabetes (T1D) in 22 Arab countries. METHODS We systematically searched 4 different literature databases (PubMed, Science Direct, Web of Science and Embase), from the date of inception until December 2017, to collect all the information about patients with T1D who developed retinopathy complications; for statistical analysis, we used MetaXL to evaluate the pooled prevalence estimate and the subgroup prevalence estimates employing double arcsine transformation and inverse variance heterogeneity models. RESULTS Our search strategy returned 475 studies, of which 39 met our inclusion criteria; of those, 16 were eligible for meta-analysis that were captured only in 15 Arab countries, through 45 years (1969-2014). The number of retinopathy patients was 396 out of 1,931 patients with T1D. The prevalence of retinopathy was 19% (95% CI 10-28%). Substantial heterogeneity was observed (Q 240.78, p < 0.0001, I2 93.77%, 95% CI 91.35-95.52%); however, no single study considerably affected the overall pooled prevalence estimate. CONCLUSION Almost one fifth of T1D patients in 15 Arab countries have diabetic retinopathy, therefore it is important to improve the care of patients with T1D and in Arab countries to avoid the development of such a devastating complication.
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Affiliation(s)
- Hatem Zayed
- Department of Biomedical Sciences, College of Health Sciences, Qatar University, Doha, Qatar,
| | - Ussama M Abdel Motal
- Sidra Medicine, Human Genetics, Translational Medicine, Qatar Foundation, Doha, Qatar
| | - Akila Gopalakrishnan
- Department of Biomedical Sciences, College of Health Sciences, Qatar University, Doha, Qatar
| | | | | | - Nasser Rizk
- Department of Biomedical Sciences, College of Health Sciences, Qatar University, Doha, Qatar
| | - Fatma M Shebl
- Yale School of Public Health, New Haven, Connecticut, USA
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Guo M, O'Connor Duffany K, Shebl FM, Santilli A, Keene DE. The Effects of Length of Residence and Exposure to Violence on Perceptions of Neighborhood Safety in an Urban Sample. J Urban Health 2018. [PMID: 29541963 PMCID: PMC5906388 DOI: 10.1007/s11524-018-0229-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Perceptions of neighborhood safety shape the well-being of individuals and communities, affecting neighborhood walkability, associated physical activity behaviors, and health conditions. However, less is known about the factors that determine perceptions of safety. One factor that may affect perceptions of neighborhood safety is the length of time someone has lived in their neighborhood. We use a representative, adult sample of urban low-income residents from the 2015 New Haven Health Survey (n = 1189) to investigate the associations between length of residence (new residents of < 1 year in neighborhood versus longer-term residents of 1 or more years in neighborhood) and perceptions of neighborhood safety (whether feeling unsafe to walk at night). We then examine the potential moderating effect of exposure to neighborhood violence on these associations. We find that the association between length of residence and perceived safety differs by exposure to neighborhood violence. Among those unexposed to neighborhood violence, longer-term neighborhood residents were more likely to feel unsafe compared to new residents (OR = 2.03, 95% CI 1.19, 3.45). Additionally, the effect of exposure to violence on feelings of safety was larger for new residents (OR = 9.10, 95% CI 2.72, 30.44) compared to longer-term residents (OR = 1.88, 95% CI 1.28, 2.77). Our findings suggest that length of residence may have implications for feelings of safety, and that experiences of violence may uniquely contribute to feelings of unsafety among new residents. These findings hold implications for interventions and policy efforts aimed at neighborhood safety improvements through community development, housing, or city urban planning initiatives, particularly for new neighborhood residents or those who experience neighborhood violence.
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Affiliation(s)
- Monica Guo
- Yale School of Public Health, New Haven, CT, USA.
| | - Kathleen O'Connor Duffany
- Yale School of Public Health, New Haven, CT, USA.,Community Alliance for Research and Engagement, New Haven, CT, USA
| | - Fatma M Shebl
- Yale School of Public Health, New Haven, CT, USA.,Community Alliance for Research and Engagement, New Haven, CT, USA
| | - Alycia Santilli
- Community Alliance for Research and Engagement, New Haven, CT, USA.,Southern Connecticut State University, New Haven, CT, USA
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Abdelrehim MG, Mahfouz EM, Ewis AA, Seedhom AE, Afifi HM, Shebl FM. Dietary Factors Associated with Pancreatic Cancer Risk in
Minia, Egypt: Principal Component Analysis. Asian Pac J Cancer Prev 2018; 19:449-455. [PMID: 29480075 PMCID: PMC5980933 DOI: 10.22034/apjcp.2018.19.2.449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Pancreatic cancer (PC) is a serious and rapidly progressing malignancy. Identifying risk factors including dietary elements is important to develop preventive strategies. This study focused on possible links between diet and PC. Methods: We conducted a case-control study including all PC patients diagnosed at Minia Cancer Center and controls from general population from June 2014 to December 2015. Dietary data were collected directly through personal interviews. Principal component analysis (PCA) was performed to identify dietary groups. The data were analyzed using crude odds ratios (ORs) and multivariable logistic regression with adjusted ORs and 95% confidence intervals (CIs). Results: A total of 75 cases and 149 controls were included in the study. PCA identified six dietary groups, labeled as cereals and grains, vegetables, proteins, dairy products, fruits, and sugars. Bivariate analysis showed that consumption of vegetables, fruits, sugars, and total energy intake were associated with change in PC risk. In multivariable-adjusted models comparing highest versus lowest levels of intake, we observed significant lower odds of PC in association with vegetable intake (OR 0.24; 95% CI, 0.07-0.85, P=0.012) and a higher likelihood with the total energy intake (OR 9.88; 95% CI, 2.56-38.09, P<0.0001). There was also a suggested link between high fruit consumption and reduced odds of PC. Conclusions: The study supports the association between dietary factors and the odds of PC development in Egypt. It was found that higher energy intake is associated with an increase in likelihood of PC, while increased vegetable consumption is associated with a lower odds ratio.
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Affiliation(s)
- Marwa G Abdelrehim
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Minia University, Minia, Egypt.,Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, CT, USA.
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Cunningham SD, Magriples U, Thomas JL, Kozhimannil KB, Herrera C, Barrette E, Shebl FM, Ickovics JR. Association Between Maternal Comorbidities and Emergency Department Use Among a National Sample of Commercially Insured Pregnant Women. Acad Emerg Med 2017; 24:940-947. [PMID: 28471532 DOI: 10.1111/acem.13215] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 04/18/2017] [Accepted: 04/25/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Evidence suggests that, despite routine engagement with the health system, pregnant women commonly seek emergency care. The objectives of this study were to examine the association between maternal comorbidities and emergency department (ED) use among a national sample of commercially insured pregnant women. METHODS We conducted a retrospective cohort study using multipayer medical claims data maintained by the Health Care Cost Institute for women ages 18 to 44 years with a live singleton birth in 2011 (N = 157,786). The association between common maternal comorbidities (e.g., hypertension, gestational diabetes) and ED use during pregnancy was examined using multilevel models, while controlling for age, region, and residential zip code. RESULTS Twenty percent (n = 31,413) of pregnant women had one or more ED visit (mean ± SD = 1.52 ± 1.15). Among those who used the ED, 29% had two or more visits, and 11% had three or more visits. Emergency care seekers were significantly more likely to have one or more comorbid condition compared to those with no emergency care: 30% versus 21%, respectively (p < 0.001). Pregnant women with asthma had 2.5 times the likelihood of having had any ED visit (adjusted odds ratio [AOR] = 2.46, 95% confidence interval [CI] = 2.32-2.62). There was a significant increase in the probability (approximately 50%) of ED use among pregnant women with diabetes (AOR = 1.47, 95% CI = 1.33-1.63) or hypertension (AOR = 1.49, 95% CI = 1.43-1.55) or who were obese (AOR = 1.55, 95% CI = 1.47-1.64). Increased odds associated with gestational diabetes were more modest, resulting in a 13% increased odds of using the ED (AOR = 1.13, 95% CI = 1.07-1.18). Less than 0.6% of pregnant women (n = 177) received emergency care that resulted in a hospital admission. The admission rate was 0.4% (189 admissions/47,608 ED visits). CONCLUSIONS Among pregnant women, comorbidity burden was associated with more ED utilization. Efforts to reduce acute unscheduled care and improve care coordination during pregnancy should target interventions to patient comorbidity.
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Affiliation(s)
| | | | | | | | - Carolina Herrera
- Department of Health Law; Policy and Management; Boston University School of Public Health; Boston MA
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Kollannoor-Samuel G, Shebl FM, Hawley NL, Pérez-Escamilla R. Nutrition label use is associated with lower longer-term diabetes risk in US adults. Am J Clin Nutr 2017; 105:1079-1085. [PMID: 28356273 DOI: 10.3945/ajcn.116.145359] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 03/02/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Regular nutrition label use may have important long-term health implications. To our knowledge, the role of nutrition label use in protecting against the development of chronic diseases was unexplored prospectively before this study.Objective: We tested the association between nutrition label use and risk of a future diabetes diagnosis in a multiethnic US cohort.Design: Data from the ongoing National Longitudinal Survey of Youth-1979 (NLSY79) were analyzed. From 2002 (baseline) to 5 follow-up time points (2004-2012), 7150 diabetes-free, multiethnic young adults were prospectively followed for a diagnosis of incident diabetes. Nutrition label use, diabetes diagnosis, time to diabetes diagnosis, and all covariates were self-reported.Results: Between January 2002 and September 2013, 430 participants (6.0%) were diagnosed with diabetes. A weighted, multivariable, extended Cox regression was conducted, which suggested that in nutrition label users, the HR of diabetes diagnosis risk decreased significantly with time (P-nutrition label use × time interaction < 0.05) compared with risk in nutrition label nonusers.Conclusions: There is an association between nutrition label use and diabetes risk in the longer term. However, additional longitudinal research with a robust dietary intake assessment is needed to test this hypothesis.
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Affiliation(s)
| | - Fatma M Shebl
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Nicola L Hawley
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
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Martinez-Brockman JL, Shebl FM, Harari N, Pérez-Escamilla R. An assessment of the social cognitive predictors of exclusive breastfeeding behavior using the Health Action Process Approach. Soc Sci Med 2017; 182:106-116. [PMID: 28437693 DOI: 10.1016/j.socscimed.2017.04.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 04/03/2017] [Accepted: 04/08/2017] [Indexed: 11/16/2022]
Abstract
RATIONALE In the United States rates of exclusive breastfeeding duration remain exceedingly low. Exclusive breastfeeding is a complex learned behavior that is influenced by social cognitive, interpersonal, and structural factors. Interventions are needed that address factors at multiple levels of the social-ecological model. This study was designed to examine the social cognitive predictors of exclusive breastfeeding behavior in a sample of low-income women attending the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) breastfeeding peer counseling program and enrolled in the Lactation Advice Through Texting Can Help (LATCH) study. OBJECTIVES The objectives were to examine whether: (1) the theoretical model, the Health Action Process Approach (HAPA), fit the data well; (2) planning mediated the effect of intentions and maintenance self-efficacy on exclusive breastfeeding; and (3) recovery self-efficacy mediated the association between maintenance self-efficacy and exclusive breastfeeding behavior. METHODS Outcome expectancies, action self-efficacy and intentions were assessed prenatally at baseline in N = 119 participants. Maintenance self-efficacy, planning, recovery self-efficacy and breastfeeding behavior were measured at two weeks post partum. Structural equation modeling with mean and variance adjusted Weighted Least Squares estimation was used to examine the applicability of the HAPA model to the data. RESULTS Phase specific self-efficacy and planning significantly predicted exclusive breastfeeding status. Planning and recovery self-efficacy mediated the association between maintenance self-efficacy and exclusive breastfeeding. Planning did not emerge as a mediator between intentions and behavior. CONCLUSION These results demonstrate the utility of the HAPA model in predicting exclusive breastfeeding behavior among low-income women attending WIC. LATCH is a theoretically sound text messaging intervention that can be used to augment and reinforce the WIC breastfeeding peer counseling process.
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Affiliation(s)
| | - F M Shebl
- Yale University, School of Public Health, New Haven, CT, United States
| | - N Harari
- Indian Health Service, Chinle, AZ, United States
| | - R Pérez-Escamilla
- Yale University, School of Public Health, New Haven, CT, United States
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Pardo CA, Farmer CA, Thurm A, Shebl FM, Ilieva J, Kalra S, Swedo S. Serum and cerebrospinal fluid immune mediators in children with autistic disorder: a longitudinal study. Mol Autism 2017; 8:1. [PMID: 28070266 PMCID: PMC5217649 DOI: 10.1186/s13229-016-0115-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 12/14/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The causes of autism likely involve genetic and environmental factors that influence neurobiological changes and the neurological and behavioral features of the disorder. Immune factors and inflammation are hypothesized pathogenic influences, but have not been examined longitudinally. METHODS In a cohort of 104 participants with autism, we performed an assessment of immune mediators such as cytokines, chemokines, or growth factors in serum and cerebrospinal fluid (n = 67) to determine potential influences of such mediators in autism. RESULTS As compared with 54 typically developing controls, we found no evidence of differences in the blood profile of immune mediators supportive of active systemic inflammation mechanisms in participants with autism. Some modulators of immune function (e.g., EGF and soluble CD40 ligand) were increased in the autism group; however, no evidence of group differences in traditional markers of active inflammation (e.g., IL-6, TNFα, IL-1β) were observed in the serum. Further, within-subject stability (measured by estimated intraclass correlations) of most analytes was low, indicating that a single measurement is not a reliable prospective indicator of concentration for most analytes. Additionally, in participants with autism, there was little correspondence between the blood and CSF profiles of cytokines, chemokines, and growth factors, suggesting that peripheral markers may not optimally reflect the immune status of the central nervous system. Although the relatively high fraction of intrathecal production of selected chemokines involved in monocyte/microglia function may suggest a possible relationship with the homeostatic role of microglia, control data are needed for further interpretation of its relevance in autism. CONCLUSIONS These longitudinal observations fail to provide support for the hypothesized role of disturbances in the expression of circulating cytokines and chemokines as an indicator of systemic inflammation in autism. ClinicalTrials.gov, NCT00298246.
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Affiliation(s)
- Carlos A Pardo
- Johns Hopkins University School of Medicine, 627 Pathology Bld., 6000 North Wolfe Street, Baltimore, MD 21287 USA
| | - Cristan A Farmer
- Pediatrics and Developmental Neuroscience, National Institute of Mental Health, Bethesda, MD USA
| | - Audrey Thurm
- Pediatrics and Developmental Neuroscience, National Institute of Mental Health, Bethesda, MD USA
| | - Fatma M Shebl
- Yale School of Public Health, Yale University, New Haven, CT USA
| | - Jorjetta Ilieva
- Johns Hopkins University School of Medicine, 627 Pathology Bld., 6000 North Wolfe Street, Baltimore, MD 21287 USA
| | - Simran Kalra
- Pediatrics and Developmental Neuroscience, National Institute of Mental Health, Bethesda, MD USA
| | - Susan Swedo
- Pediatrics and Developmental Neuroscience, National Institute of Mental Health, Bethesda, MD USA
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Kollannoor-Samuel G, Shebl FM, Hawley NL, Pérez-Escamilla R. Nutrition facts panel use is associated with higher diet quality and lower glycated hemoglobin concentrations in US adults with undiagnosed prediabetes. Am J Clin Nutr 2016; 104:1639-1646. [PMID: 27797707 DOI: 10.3945/ajcn.116.136713] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 09/22/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The majority of US consumers use the nutrition facts panel (NFP) or health claims for food selections. Although previous studies have consistently reported positive impacts of NFP use on dietary intake, evidence regarding the effect of the use of health claims, either alone or in combination with the NFP, on diet quality and health outcomes is scarce. OBJECTIVES Our primary objective was to test for associations of the use of food labels (the NFP or health claims) with overall diet quality in individuals with prediabetes. In addition, we examined the association between food label use and glycated hemoglobin (HbA1c) concentrations. DESIGN We conducted a weighted linear regression, which was appropriate for a complex sampling survey, with the use of cross-sectional data from 2654 US adults with undiagnosed prediabetes who participated in the 2005-2010 NHANES cycles. The following 4 categories of food label (NFP or health claims) use were identified: 1) both labels, 2) health claims only, 3) neither label, and 4) the NFP only. Healthy Eating Index-2010 score, which we used to assess diet quality, was calculated from two 24-h recalls. Blood samples for analyzing HbA1c concentrations (glycemic control) were collected in the mobile examination center. RESULTS The overall diet quality scores for the use of both labels [b: -2.76 (95% CI: -5.04, -0.48); P = 0.019], of health claims only [b: -3.46 (-6.64, -0.28); P = 0.033], and of neither label [b: -4.01 (-5.75, -2.28); P < 0.001] were lower than those of NFP-only users. Moreover, HbA1c concentrations of users of both labels [b: 0.09% (95% CI: 0.03%, 0.16%); P = 0.008] and health claims only [b: 0.13% (95% CI: 0.02%, 0.25%); P = 0.021] were higher than those of NFP-only users. CONCLUSIONS In participants with undiagnosed prediabetes, the use of health claims alone, of both labels, or of neither label (compared with the use of the NFP only) was associated with poorer diet quality. In addition, users of neither label and users of both labels had poorer glycemic control. Further studies are needed to understand why the use of health claims may not be health promoting in this high-risk population.
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Affiliation(s)
| | - Fatma M Shebl
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Nicola L Hawley
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
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Yang B, Shebl FM, Sternberg LR, Warner AC, Kleiner DE, Edelman DC, Gomez A, Dagnall CL, Hicks BD, Altekruse SF, Hernandez BY, Lynch CF, Meltzer PS, McGlynn KA. Telomere Length and Survival of Patients with Hepatocellular Carcinoma in the United States. PLoS One 2016; 11:e0166828. [PMID: 27880792 PMCID: PMC5120796 DOI: 10.1371/journal.pone.0166828] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/05/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Telomere shortening is an important molecular event in hepatocellular carcinoma (HCC) initiation; however, its role in HCC progression and prognosis is less clear. Our study aimed to examine the association of telomere length with survival of patients with HCC. METHODS We measured telomere length in tumor and adjacent non-tumor tissues from 126 persons with HCC in the United States (U.S.) who were followed for mortality outcomes. Relative telomere length (RTL) was measured by a monochrome multiplex quantitative polymerase chain reaction assay. Multivariable Cox proportional hazards modeling was used to calculate hazard ratios (HRs) and 95% CIs for the association between telomere length and all-cause mortality. We also examined associations between telomere length and patient characteristics using multiple linear regression. RESULTS During a mean follow-up of 6.0 years, 79 deaths occurred among 114 individuals for whom survival data were available. The ratio of RTL in tumor relative to non-tumor tissue was greater for individuals with regional or distant stage tumors (0.97) than localized stage tumors (0.77), and for individuals with grade III or IV tumors (0.95) than grade II (0.88) or grade I (0.67) tumors. An RTL ratio ≥1 was not associated with survival (HR 0.92, 95% CI 0.55, 1.55) compared to a ratio <1, after adjusting for age at diagnosis, sex, tumor stage and tumor size. Similarly, RTL in the tumor and non-tumor tissue, respectively, were not associated with survival. CONCLUSIONS This U.S. based study found that telomeres may be longer in more aggressive HCCs. There was no evidence, however, that telomere length was associated with survival of patients with HCC. Future investigations are warranted to clarify the role of telomere length in HCC prognosis.
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Affiliation(s)
- Baiyu Yang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, 20892, United States of America
| | - Fatma M. Shebl
- Yale University School of Public Health, New Haven, CT, 06520, United States of America
| | - Lawrence R. Sternberg
- Pathology-Histotechnology Laboratory, Frederick National Laboratory for Cancer Research, Frederick, MD, 21701, United States of America
| | - Andrew C. Warner
- Pathology-Histotechnology Laboratory, Frederick National Laboratory for Cancer Research, Frederick, MD, 21701, United States of America
| | - David E. Kleiner
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, 20892, United States of America
| | - Daniel C. Edelman
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, 20892, United States of America
| | - Allison Gomez
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, 20892, United States of America
| | - Casey L. Dagnall
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, 20892, United States of America
- Cancer Genomics Research Laboratory, Leidos Biomedical Research, Inc. Frederick National Laboratory for Cancer Research, Frederick, MD, 20892, United States of America
| | - Belynda D. Hicks
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, 20892, United States of America
- Cancer Genomics Research Laboratory, Leidos Biomedical Research, Inc. Frederick National Laboratory for Cancer Research, Frederick, MD, 20892, United States of America
| | - Sean F. Altekruse
- Division of Cancer Control & Population Sciences, National Cancer Institute, Bethesda, MD, 20892, United States of America
| | - Brenda Y. Hernandez
- University of Hawaii Cancer Center, Honolulu, HI, 96813, United States of America
| | - Charles F. Lynch
- University of Iowa College of Public Health, Iowa City, IA, 52242, United States of America
| | - Paul S. Meltzer
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, 20892, United States of America
| | - Katherine A. McGlynn
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, 20892, United States of America
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Yang B, Shebl FM, Sternberg LR, Warner AC, Kleiner DE, Edelman DC, Gomez A, Dagnall CL, Hicks BD, Altekruse SF, Hernandez BY, Lynch CF, Meltzer PS, McGlynn KA. Abstract 818: Shortened telomere length in hepatocellular carcinoma in the United States. Cancer Res 2016. [DOI: 10.1158/1538-7445.am2016-818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Telomeres play an important role in the maintenance of chromosomal stability. It has been previously reported that telomere length is shortened in hepatocellular carcinoma (HCC) compared to paired non-tumor tissue. However, most studies have been conducted in high-risk regions such as Asia. To date, no prior study has examined telomere length and HCC in the United States, a low risk region where HCC etiology may differ from that of high risk regions.
Methods: We measured telomere length in 127 paired tumor and non-tumor tissue samples from persons with HCC in Iowa, Hawaii and Connecticut. Formalin-fixed, paraffin-embedded tissues were collected at the time of diagnosis. Relative telomere length was measured by a monochrome multiplex quantitative PCR assay. The Wilcoxon signed-rank test was used to compare telomere length between tumor and paired non-tumor tissues. Cox proportional hazards modeling was used to estimate the association between telomere length and mortality, adjusting for age at diagnosis, sex, and tumor stage and size at diagnosis.
Results: Of the 127 pairs of samples, telomere length was shorter in the tumor in 88 pairs (69%), longer in the tumor in 33 pairs (26%) and the same length in the tumor and non-tumor tissue in 6 pairs (5%). Overall, the HCC tissues had statistically significantly shorter telomere length than their matched non-tumor tissues (p < 0.01). The proportion of pairs in which the tumor telomere was shorter than non-tumor was higher among those with localized stage tumors (81%) compared to those with regional or distant stage tumors (50%) (p < 0.01 after adjusting for age at diagnosis, sex, and source of the case). In addition, we observed a 119% higher risk of mortality (adjusted relative risk 2.19) among persons whose tumors had shorter telomeres than their non-tumor tissue, compared to persons whose tumors had longer telomeres; however, the confidence interval was relatively wide (0.94-5.12).
Conclusion: Using tissue samples from persons with HCC in the United States, we found that telomere length was shorter in tumor tissue compared to paired non-tumor tissue, especially among localized stage tumors. In addition, there was a suggestion that tumor telomere shortening might be associated with higher risk of mortality. Together, these results may provide insight into the role of biological mechanisms associated with telomere shortening and into the prognosis of HCC in lower risk populations.
Citation Format: Baiyu Yang, Fatma M. Shebl, Lawrence R. Sternberg, Andrew C. Warner, David E. Kleiner, Daniel C. Edelman, Allison Gomez, Casey L. Dagnall, Belynda D. Hicks, Sean F. Altekruse, Brenda Y. Hernandez, Charles F. Lynch, Paul S. Meltzer, Katherine A. McGlynn. Shortened telomere length in hepatocellular carcinoma in the United States. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 818.
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Affiliation(s)
- Baiyu Yang
- 1National Cancer Institute, Bethesda, MD
| | | | | | | | | | | | | | - Casey L. Dagnall
- 3National Cancer Institute/Frederick National Laboratory for Cancer Research, Bethesda/Frederick, MD
| | - Belynda D. Hicks
- 3National Cancer Institute/Frederick National Laboratory for Cancer Research, Bethesda/Frederick, MD
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Kollannoor-Samuel G, Shebl FM, Segura-Pérez S, Chhabra J, Vega-López S, Pérez-Escamilla R. Effects of Food Label Use on Diet Quality and Glycemic Control Among Latinos With Type 2 Diabetes in a Community Health Worker-Supported Intervention. Am J Public Health 2016; 106:1059-66. [PMID: 27077337 PMCID: PMC4880245 DOI: 10.2105/ajph.2016.303091] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine the impact of an intervention led by community health workers (CHWs) on food label use and to assess whether food label use and diet quality mediate the intervention's impact on glycemic control. METHODS From 2006 to 2010, 203 Latinos (intervention group, n = 100; control group, n = 103) in Hartford County, Connecticut, with type 2 diabetes were randomized to an intervention that included 17 CHW-led home-based sessions over a 12-month period in addition to the standard of care available in both study arms. Data on food label use, diet quality, covariates, and glycated hemoglobin (HbA1c) were collected at baseline and at 3, 6, 12, and 18 months. Data were analyzed via mixed effects and multilevel structural equation modeling. RESULTS Food label use in the intervention (vs control) group was significantly higher at 3, 12, and 18 months (odds ratio = 2.99; 95% confidence interval = 1.69, 5.29). Food label use and diet quality were positive mediators of improved HbA1c levels. CONCLUSIONS Culturally tailored interventions led by CHWs could increase food label use. Also, CHW-delivered food label education may lead to better diet quality and improve glycemic control among Latinos with type 2 diabetes.
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Affiliation(s)
- Grace Kollannoor-Samuel
- Grace Kollannoor-Samuel, Fatma M. Shebl, and Rafael Pérez-Escamilla are with the Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT. Sofia Segura-Pérez is with the Center for Community Nutrition, Hispanic Health Council, Hartford, CT. Jyoti Chhabra is with Hartford Hospital, Hartford, CT. Sonia Vega-López is with the School of Nutrition and Health Promotion, Arizona State University, Phoenix
| | - Fatma M Shebl
- Grace Kollannoor-Samuel, Fatma M. Shebl, and Rafael Pérez-Escamilla are with the Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT. Sofia Segura-Pérez is with the Center for Community Nutrition, Hispanic Health Council, Hartford, CT. Jyoti Chhabra is with Hartford Hospital, Hartford, CT. Sonia Vega-López is with the School of Nutrition and Health Promotion, Arizona State University, Phoenix
| | - Sofia Segura-Pérez
- Grace Kollannoor-Samuel, Fatma M. Shebl, and Rafael Pérez-Escamilla are with the Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT. Sofia Segura-Pérez is with the Center for Community Nutrition, Hispanic Health Council, Hartford, CT. Jyoti Chhabra is with Hartford Hospital, Hartford, CT. Sonia Vega-López is with the School of Nutrition and Health Promotion, Arizona State University, Phoenix
| | - Jyoti Chhabra
- Grace Kollannoor-Samuel, Fatma M. Shebl, and Rafael Pérez-Escamilla are with the Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT. Sofia Segura-Pérez is with the Center for Community Nutrition, Hispanic Health Council, Hartford, CT. Jyoti Chhabra is with Hartford Hospital, Hartford, CT. Sonia Vega-López is with the School of Nutrition and Health Promotion, Arizona State University, Phoenix
| | - Sonia Vega-López
- Grace Kollannoor-Samuel, Fatma M. Shebl, and Rafael Pérez-Escamilla are with the Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT. Sofia Segura-Pérez is with the Center for Community Nutrition, Hispanic Health Council, Hartford, CT. Jyoti Chhabra is with Hartford Hospital, Hartford, CT. Sonia Vega-López is with the School of Nutrition and Health Promotion, Arizona State University, Phoenix
| | - Rafael Pérez-Escamilla
- Grace Kollannoor-Samuel, Fatma M. Shebl, and Rafael Pérez-Escamilla are with the Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT. Sofia Segura-Pérez is with the Center for Community Nutrition, Hispanic Health Council, Hartford, CT. Jyoti Chhabra is with Hartford Hospital, Hartford, CT. Sonia Vega-López is with the School of Nutrition and Health Promotion, Arizona State University, Phoenix
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